Know My Voice®
July 19, 2026
Anyone who works with technology development knows that there will be a time when someone will say, “That is a training issue”. This statement often comes after someone asks, “how will the user know how to do <insert workflow step>?”
Sometimes the technical steps are not necessarily intuitive to the user’s anticipation of what to do next. This is a mismatch in the user experience. When this occurs, the user has (at best) confusion in trying to identify the next step. The confusion can lead to extreme frustration that halts progress toward completing the next step in the process (and lost time).
Example: Pop Up Window Advertisements
Consider when you see a pop-up window to save you 10% on your first order for any given advertisement. You may or may not be interested in the welcome discount. If not, it can be quite difficult to find the “X” on the screen to exit the offer. You look around all four corners and sometimes need to locate the very faint area where you can exit out. If not found, you could exit the screen or put in your email to just get to what you wanted to see. (Of note, this is likely by design to obtain your email address ).
The lack of visibility of the “X” is a user experience or more specifically, a usability design issue. Sure, one could say it is a training issue and tell each person they need to look VERY CAREFULLY each time they accidentally find themselves with a discount offer. However, this becomes the user’s issue rather than the system design issue that removes this extra step. This usability design issue turns into a training issue. The usability shifts from the responsibility of the system designers to that of the individual to “learn” how to “workaround” the intended design.
Healthcare Training Issues
Now, let us look at healthcare. Healthcare is dependent upon clinical and administrative information systems to manage the individual and population level care. However, most clinicians are not formally educated on the foundations of informatics and/or information system design. Therefore, there is an inherent concern and perhaps intimidation faced where there is concern about whether they are charting the right way.
Some clinicians will over chart while others will struggle to know what exactly needs to be charted and may unintentionally miss something. The extremes here are a result of a culture, especially in nursing, of “if it is not documented, it is not done”. However, when it becomes hard to know where to go next or how to enter some data correctly, you see the (largely unintentional) risk of error. Add to this baseline, a handful of “training issues” and we have just added more stress to an already stressed and fatigued workforce.
Of course there are some aspects that do require training. However, for a moment think about how many times you have turned to watch a video or training session to use your new smart phone. Much of what you need to be able to do with your smart phone or device can be figured out without a training session.
We should be striving for this type of user experience with healthcare technology. The need for formal training sessions should be minimal or very brief. Instead, the design of the systems should be such that the user is able to follow what the next step is through an intuitive human computer interaction experience.
There is an abundance of qualitative and quantitative data to show that nurses, doctors, and healthcare professionals in general are working against the clock each day. There are never enough minutes to go around for everything that needs to get done in that shift. To add more things to what is expected of them will only increase the burden felt rather than create relief.
Healthcare cannot be delivered without the use of technology. However, we must consider that we have a workforce already spread thin. Instead of putting more responsibility through “training issues”, why not create a sense of ease and/or intuitive flow for them to experience each day?
~ Dr. Kelley
February 01, 2018
This week I visited an acupuncturist for the first time. The acupuncturist asked me about my past medical history as well as my current health. She asked me about when I last had labs drawn and if I knew the results.
I knew I had labs drawn recently, however I had no recollection of what was drawn during my last physical nor what those lab values were as a result.
I had to tell her, ‘I don’t know.’ (I also didn’t know I would be asked about them).
November 05, 2017
Earlier this week I spent some time speaking to a group of graduate nursing students at a college in Boston Massachusetts. We talked about the foundations of nursing informatics, electronic health records (EHRs), apps, and problem solving in the field.
Each student mentioned something that could be improved with regard to their current health IT environment. I mentioned that each one of them had an opportunity to help solve those problems. The question from one student was, “where do I start? How do I help solve some of these problems?”
Her question was the BEST question of the night. Where or how do I start is usually the first barrier toward moving anything forward.
To start, KNOW that you don’t need to have a technical background to provide a suggestion for improvement. What you do need, YOU ALREADY HAVE and that is your clinical expertise and knowledge of how to care for patients.
So, if you recognize a problem that has the potential to impact care delivery in your area (e.g., inpatient, ICU, ED, PACU, Ambulatory) and is a hindrance toward the delivery of quality patient care, take a closer look.
Take a closer look beyond the technology to see why it may be a problem. What is the issue? Is it a process issue (e.g., workflow)? Is it a people issue (e.g., non-compliance)? Is it a technology issue (e.g., design/functionality)?
Then observe and ask questions. Who else is impacted? Does it bother them too? Why hasn’t anyone said anything?
Next, think about what would be the way to solve it. How could it be made better? What would be a better situation. This is where you should not focus on what you do or do not know about technology but rather how technology could support you in your delivery of care.
Finally, find someone to share your findings with and ensure that you get it to the right person.
We cannot make improvements without knowing what the issues are that are impacting care. Those in the roles of care delivery are the BEST equipped to offer suggestions to others that can evaluate and begin to implement new changes.
Joining a council, becoming a Super User or a Subject Matter Expert (SME) are three ways to get more experience and learn more about the role of technology and informatics in nursing and health care delivery.
October 02, 2017
Did you know that the first electronic health records (e.g., EHRs) were developed in the late 1960’s and early 1970’s? I did not know this when I first came to know them in the early 2000’s. I naively thought, ‘how hard can it be to take paper records and turn them into an electronic form?’.
Well, the answer to that question, it is very hard! Despite the efforts during my first few years with EHRs, I was unaware of the fascinating history that came alongside this new way of digitalizing patient information until I began writing my book on EHRs. EHRs are a case study for demonstrating that healthcare innovation is a different marketplace. With so many influential factors, bringing innovation to healthcare environments takes the time that it takes.
Dr. Lawrence Weed conceptualized the idea for a ‘problem oriented medical record’ in 1968. His thoughts were published in the New England Journal of Medicine. He saw the opportunity to leverage technology in a way that physicians could manage patient information according to problems and understand the whole patient as a person. Dr. Weed saw the opportunity to support the clinician with information needed for decision making, and care delivery. Weed did not use the term ‘electronic health record’ or EHR, nor did any of his peers that were developing the first EHR systems. The term used at that time was ‘computerized patient record’ or CPRs.
During that time, several organizations began developing systems for use within their facilities: Duke, Massachusetts General Hospital, Beth Israel Deaconess Medical Center and the Department of Veterans Affairs are just a few of these pioneers. These efforts began nearly 50 years ago. However, fast forward 40 years and the United States had been at less than 2% adoption in 2009.
While we may not think of it now, the EHR is an innovation in healthcare. AHRQ defines healthcare innovation as, “the implementation of new or altered products, services, processes, systems, policies, organizational structures, or business models that aim to improve one or more domains of health care quality or reduce health care disparities” (https://innovations.ahrq.gov/faq). The EHR is an example of how diffusing innovation in healthcare does not happen overnight.
I sometimes wonder where we, the United States, would be had the HITECH Act not made financial incentives available to accelerate the adoption of EHRs in health care organizations. I suspect the adoption rates would not be what they are today. As of the end of Q2 of this year, less than 2% of hospitals and outpatient practices were at a Stage 0 on the HIMSS EMRAM (electronic medical record adoption model). In less than 10 years, the United States went from less than 2% adoption to less than 2% non-adoption!
Now, imagine you were Dr. Lawrence Weed or any of the pioneers that developed the early EHRs. Imagine the hurdles experienced to bring the idea and early concepts to life and acceptance. Imagine how many people said ‘that will never happen’ or ‘you can’t do that’ and over how long of a period of time it likely was expressed by others. Fifty years is a very long time.
EHRs faced financial, technical, organizational and legal barriers toward rapid adoption. The HITECH Act helped to breakdown some of the financial barriers. In general, healthcare innovation needs to overcome each of these barriers toward successful implementation and adoption.
In some cases, the technical environment and the organizational culture wasn’t quite ready for EHRs. Legally, the protection of electronic PHI was not defined until 2003 with the Security Rule. Thus, despite the conceptualization and recognition of the potential in the 1960’s, the healthcare innovation took the time that it needed before it could be accepted into the environment.
I believe this is a helpful perspective for those that are developing new innovations in healthcare. The general ecosystem of innovation tends to paint a picture that one can develop a solution and have it lead to rapid widespread adoption within a very short period of time. (For example, Instagram started in 2010 and was sold to Facebook in 2012 for 1B). Yet, the healthcare marketplace is not the same as the consumer marketplace. In many cases, the consumer of the innovation in healthcare is not the purchaser of the product. Additionally, the previously mentioned barriers become less conflated when managed at an individual (e.g., person/user) level rather than a system (e.g., health care organizational) level. Thus, the adoption of new innovations within healthcare organizations requires the time that it takes.
Best,
Dr. Tiffany Kelley RN
For more information about my book, Electronic Health Records for Quality Nursing and Healthcare, visit Destech Publications at: http://bit.ly/2a6pJpz.
September 18, 2017
I knew very little about entrepreneurship when I started down this path several years ago. I had the idea and vision for Know My Patient®. I knew that every bedside nurse deserves an opportunity to have accurate, up to date information needed for patient care at their fingertips. I knew chasing after information was a waste of their time and energy when it could be sent to them electronically and available in a mobile device from the comfort of their pocket. I knew nurses wanted to feel like nurses and not data entry specialists. Thus, I decided with these knowns, the best way to bring Know My Patient® to life would be to start a company, Nightingale Apps.
However, unlike the rest of my career to date at that time, I did not have a nursing mentor to help guide me through the general process of taking an idea, bringing it to life, and then turning it into a company. At that time, I did not know of any other Nurse Entrepreneurs. While I didn’t see that as a barrier to my desired pathway, many others would often try to deter me from the chosen path. I reached a point where I could see in someone’s eyes that he or she was thinking. “You are going to do what?”. Instead of letting the reactions deter me, I decided to begin to learn what it meant to be an entrepreneur and learn from others.
The word entrepreneur is as “one who organizes, manages, and assumes the risks of a business or enterprise”. Applying that definition, the Nurse Entrepreneur is one who has identified an opportunity to solve a problem in health care that can be executed through a business entity. We all know there are many opportunities to improve health care. However, we, as nurses, don’t all realize that deciding to take on that opportunity can be a viable, profitable option that drives an impact on those whom you are providing your product, service or solution.
I remember hearing from someone several months ago, “You’re a nurse and an entrepreneur? I didn’t know you could do that.” That statement gives me a chuckle because there really are no barriers to entrepreneurship. There are no degree requirements or certifications required to start down this path. What you do need is an entrepreneurial way of thinking, an idea, and a plan to execute that you are willing to adjust as you begin to pave your own path.
You might be thinking, “Well, is it (e.g., entrepreneurship) hard?” Yes, it is hard. Nursing school is hard. The NCLEX is hard. Caring for sick and dying patients is hard. Entrepreneurship is a different kind of ‘hard’ work. However, I always come back to what it felt like to care for patients and their families. Nurses save lives every day. If you can do that, you are well equipped for a path toward entrepreneurship. However, you have to want to do it and it will not be a path for everyone. That is ok too.
Over the last several months I’ve been introduced to several Nurse Entrepreneurs and Innovators. With each new week, I learn of other nurses that have decided to create their own path and are thriving in their niche. I have also learned of nurses who have created solutions in health care that I never knew started from a nurse. For example, the crash cart and the Wong-Baker Faces Scale both started from a nurse who identified a problem with the current method of managing code situations or childhood pain.
I often talk to groups about how we as a profession need to be our best advocates. We need to demonstrate the power of our profession by modeling the way to others. Instead of complaining about some of our professional challenges (my personal pet peeve is how nurses are portrayed in television), we need to turn that around and be more on the offense in a positive constructive way. We must show others what we do and how we do it. Perhaps we will inspire others to become nurses. Perhaps we will reduce stereotypes of what we do at the bedside or what our capabilities are as professional nurses. With so many available outlets at our fingertips today, we have the ability to make an impact for others with minimal barriers.
To take a first step toward this, I decided that we, Nightingale Apps LLC, would form an initiative to showcase other entrepreneurial (and intrapreneurial) nurses who are identifying opportunities where they are making a strong, positive impact on health care through their unique skill sets and perspective on what is currently missing. This initiative is called, Nightingale’s Innovative Nurses and we will be showcasing these nurses through our Nightingale Apps newsletter and social media outlets.
Our first Innovative Nurse, Andrew Craig, RN, is a Travel Nurse that has started his own Travel Nurse business, HubbleSweet PLLC and has a YouTube channel with videos to help educate nurses on the Travel Nurse industry. You can learn more about him and his entrepreneurial mindset here: .
I’d like to invite any of you reading this who are interested in learning more or being featured to either reach out to me directly or to our team at contact@nightingaleapps.com. We’d love to learn about what you are doing and/or someone else that you might know who fits this description. The Nightingale Apps team and I are excited about this effort. As much as we need nurses to care for patients, we also need nurses to pave new paths for those to come and give a view into what else is possible within the nursing profession.
Best,
Dr. Tiffany Kelley
September 11, 2017
Have you ever found yourself thinking ‘do I nurse the computer or nurse the patient?’ during your nursing shift? If the answer is yes, you are not alone. This phenomenon of ‘nursing the patient versus nursing the computer’ did not exist when I was a new nurse in 2000. This phenomenon emerged over the last decade as the nation has moved from a paper-based medical record system to the use of electronic health records (EHRs). However, unless you are a nurse (or health care professional) actively involved in providing direct patient care, this phenomenon may not be well known to you.
The phenomenon of nursing the patient versus nursing the computer is an internal struggle. The internal struggle is visible in the nurse’s behavior but not often verbalized by the nurse. As nurses, we are there to care for our patients. I have yet to meet a nurse who entered the profession because of their joy for charting. Instead, entering the profession often comes from the joy of caring for other people, our patients, during our shifts.
We, as nurses, know charting is part of our role and responsibilities. We learn this through nursing school courses, practicums and our preceptorship when first starting as a nurse in the health care organization. We respect the practice of charting, or documenting, on our patient. Yet, in many cases, the patient should be the priority over that of the chart. Thus, our instinct is often to care for the patient before caring for the patient’s record of information. However, there are times when this decision becomes a struggle for the nurse.
Dr. Kelley has 25 years of nursing and healthcare experience. She spent the last 21 years working in the field of nursing informatics. Read more
