Veterinarian Office System

Part 1: Defining the requirements

Fall Semester 2000 Project Team Members

Ed Hess

James Irizarry

Toni Pashley

Erica Wingo

Project Description

Medical file maintenance has always been a very important yet laborious task in a veterinary clinic. There is a lot of information that must be tracked for an office to run efficiently. Information such as patient records, pharmaceutical inventory, and billing must be stored. More over, this information must be stored in such a way that permits easy retrieval and interpretation when needed. Many people could also require access to this information at the same time, thus forcing people to develop a sharing scheme.

Techniques for the storage of this information vary from clinic to clinic, as needs or resources demand. From paper files to computer databases, all clinics have their particular methods. But there are problems with these systems. Paper files consume a lot of space and system interfaces are difficult to use effectively without training. Collaboration is a challenge since multiple users may need simultaneous access to modify patient files. Further, because the examination requires a “hands-on” technique, the vet technician and vet are forced to wait until the exam is over before having the opportunity to record the discussions and results. It is highly likely that pertinent information will be forgotten.

Our goal is to develop a veterinary office record system that allows for easy input and retrieval of information. Our main focus will be the process of check-in, examination, and checkout of a patient. This system will enhance the communication capabilities of the people involved in performing the tasks. It will also support scheduling and reminder capabilities, thus meshing many tasks into a single system. This system will help by making record keeping easier, faster and more interactive, thus giving a chance for people to increase their productivity.

User Profiles

The three main users in a typical veterinary office are: veterinarian, front office staff, and veterinary technician.

Veterinarian

The veterinarian's time is largely spent in performing examinations of the pet and conferring with the pet owner, and these are often done concurrently. The exam requires manipulation of a variety of artifacts such as an otoscope, stethescope, or microscope. They may also take laboratory samples and perform laboratory work. For any examination, the veterinarian performs "SOAP", or "SOAP's the record". SOAP is an acronym describing a standard procedure for performing a veterinary examination and will be explained in the task analysis.

During the examination, the veterinarian may need to restrain the animal, while observing and taking mental notes of the results of their observations. The results of heart rate, respiration rate, and temperature measurement have to be placed in working memory and recorded at a later time, either on paper or in the computer depending upon the veterinary office. Several segments of the exam, or the entire examination may be performed before recording "SOAP". The assessment phase is performed in their head, evaluating and eliminating possibilities suggested by the S and O data, and comparing them with information stored in their long-term memory.

Aside from the examination, the veterinarian performs other duties such as dispensing of medication. The veterinarian also routinely educates pet owners on the proper use of medications, as well as other topics related to the care of their pets. They must also deliver delicate news to pet owners if their pet is in grave condition.

Front Office Staff

The front office staff is required to perform and shift quickly between varieties of short tasks during the course of a day. They interact with pet owners in person and over the phone, which requires patience and tact. To do their job well, they need to have good organizational skills. They need to understand the functioning of the office computer system that may include functions for billing, storing patient records and medical procedure information. In an office with a primarily paper-based records system, physical delivery of appropriate records is required, as is continued manual maintenance of the filing system. It is important to keep track of the status of various individuals, such as where they are, how long they have been waiting, and for what they are waiting. They may have to deal with unfamiliar terminology depending upon their experience and training. It is also helpful if they are able to elicit fairly complete histories from the pet owners regarding the reason for the visit. They also act as a central communications area for the veterinary office.

Veterinary Technician

The veterinary technician's (vet tech) job requires a significant amount of physical labor, such as transporting animals, restraining animals, and cleaning cages and examination rooms. The veterinary technician may manipulate artifacts such as needles and syringes when performing tasks such as drawing and administering shots, and they may be required to take, transport and perform basic testing on biological samples depending on the office they work in. The technician must communicate with pet owners, front office staff, and veterinarians. The technician may take patient histories from the pet owners, and perform a small amount of data recording (on paper or by entry into computer) related to this history.

Task Analysis

Task Environment

We observed two separate animal hospitals. Both of the animal hospitals include a patient waiting room, a front office, examination rooms, a surgery, boarding area and laboratory. Events occur simultaneously in the hospital i.e., boarding, grooming, examinations, and surgery. Hospital employees include veterinarians, front office staff, and veterinary technicians. The communication and collaboration of these individuals is critical for our focus on the patient examination process.

A patient may arrive with or without an appointment and it is the responsibility of the hospital staff to provide quality care to the patient regardless of time constraints. For our analysis we observed examinations by appointment and walk-ins. In the hospitals we observed, a veterinarian is responsible for managing his daily schedule to include surgeries, appointments, walk-in exams, and treatment of boarded animals. The vet must coordinate his or her schedule with a veterinary technician in order to have assistance throughout the day. A front office staff member may change this schedule at any time if a patient schedules an exam. Even though there is a proposed schedule, the changing environment means tasks are sometimes cut short and people are sometimes difficult to locate.

Sometimes there is a long wait for exams. The health of a pet can be a sensitive issue with an owner. In our observations there were exams at each hospital where the patients were dying. In one case the veterinarian was taking a longer time than expected with a patient because of this sensitivity of this issue.

At both hospitals, most of the staff are accustomed to handling animals. Veterinarians have stated that animals can be difficult at times. They can be hard to control, noisy, and sometimes aggressive. The hospital staff must be able to handle multiple types of animals that walk through the door. Oftentimes during the examination the animal must be constrained to administer shots or perform a procedure. A veterinarian may ask the veterinarian technician and or the patient’s owner to assist them.

Due to the hectic schedules and sensitivity of medical information at an animal hospital, it is important that the information documented in the medical file be readable and accessible by all individuals that are involved in the collaboration. Sometimes an owner drops a patient off and does not stay to participate in the exam. The vet is alone to make the diagnosis with no benefit of speaking with the owner. The front office staff becomes the point of contact with the patient’s owner and must facilitate the communication to and from the veterinarian.

Task Analysis – A Detailed Illustration

The veterinarian is the primary user in the patient examination process but for our task analysis, we focus on a hospital artifact, the patient’s medical file (See Figure1).

This medical file is important to the exam process because it is the living record of the entire exam. The tasks the veterinarian performs are critical to the exam and are recorded in this artifact. Beginning with the patient check-in, throughout the exam, and ending with the check out, several individuals interact with this document. The artifact reflects the collaboration of the specific tasks each individual must perform in the exam process.

Figure 1 – Paper-based System

We performed a Hierarchical Task Analysis for the artifact. At each hospital we observed a typical working day, including observations of both the front office process and examination room. Most exams we observed were routine visits for updating vaccinations.

The major tasks were similar for both hospitals but the sub tasks differ. The first task analysis follows an artifact in an animal hospital, with a paper process for recording the patient exam. The second analysis is for the hospital with a computer system for recording the exam. In both environments the artifacts follows a similar path.

The front office is the main artery of the system. This is where interaction with the artifact begins and ends. Each veterinarian receives a medical file from the front office. They interpret the information and proceed with the examination. Several veterinarians receive medical files and perform patient examinations simultaneously.

When performing the exam, the vet is trained to follow a specific process, SOAP. SOAP stands for Subjective, Objective, Assessment, Plan. The exam begins with the vet or vet technician inquiring about the pet’s current health and history (Subjective). Next, the vet reviews the pet’s current vitals- temperature, weight, pulse, and lab results if available (Objective). Using both the subjective and objective information, the vet assesses the patient’s condition, rules out possible problems or diseases and makes a diagnosis (Assessment). Finally, the vet prescribes a course of action or treatment (Plan). The front office staff starts the SOAP process. Since a vet may not see the same patient every time, it is important that they use the SOAP process to clearly document the case for someone else to read. For each time a veterinarian walks into the exam room, they may have to review another vet's documentation and rethink the case.

During the exam the vet speaks the entire time while they are examining. They explain to the owner the procedures and ask questions about the patient. At times a veterinarian is required to counsel the pet owner for health and dying matters. Overall, the veterinarian is an educator during the examination.

Paper-based System

Task 1 – Check-in

Task 2 – Examination

Task 3 – Check out

Computer-based System

Task 1 – Check-in

Task 2 – Examination

Task 2 – continued

Task 3 – Check out

System Description

The system we would design for veterinarian offices would ideally meet the needs of all office processes. The system should also support those attributes that are valued within the business practice and are required in order to execute the processes efficiently.

The focus and major function of the system we will design is the facilitation of the patient examination process.

The system must allow for effective collaboration and communication between the different actors: front office staff members, veterinary technicians, and veterinarians. The scenarios presented below identify the multiple areas within the patient examination process where collaboration is key. The collaborative nature of the process requires that the system be an inherent part of the process, where information transfer is quick and easy, the cognitive load is reduced and risk factor for mistakes is decreased.

The patient examination process can be broken down into three high-level tasks: check-in, examination, and checkout. First, a front office staff member checks-in the patient. Second, a vet technician may begin the exam and a vet completes it. Finally, a front-office staff member checks out the patient. It is possible that up to three different people may interact within the system in one revolution of the process. Collaboration through knowledge transfer is a must.

A system that offers hands-free operation would be desirable. Since the examination requires a “hands-on” technique, the technician and vet are forced to wait until the exam is over before having the opportunity to record the discussions and results (SOAP). It is highly likely that pertinent information will be forgotten. Our system would allow for real-time documentation so that information does not get lost.

Another important aspect of the system would be accountability. In any medical field, there is liability. It is important to track who did what, when and why. The system we develop will require employee sign-off at every major knowledge or responsibility transfer. The system would support information queries by procedure, date, employee or some combination of the three.

An additional system attribute would be information maintenance and tracking. What were the grooming sales for July? How much Rimadyl have we dispensed? Do we need to reorder Hill's Science Diet Canine Lamb & Rice Meal? Who worked overtime in August? The system we would design would be capable of tracking valuable information from client accounts receivable to appointment scheduling. Maintaining such an abundance of information could be simplified with an extremely robust system that allows for flexibility of data manipulation and retrieval.

Assessment of Current Systems

Our team performed a task analysis on two vet offices. Although their processes are similar, they are diverse in their file-handling system. One office is mostly paper-based and the other is entirely computer-based. They both share the same goal- to examine and treat patients successfully and efficiently, however, there are numerous aspects of both systems that could be improved.

Both veterinarians interviewed use an exam process called SOAP. SOAP stands for Subjective, Objective, Assessment, Plan. The exam begins with the vet or vet technician inquiring about the pet’s current health and history (Subjective). Next, the vet reviews the pet’s current vitals- temperature, weight, pulse, and lab results if available (Objective). Using both the subjective and objective information, the vet assesses the patient’s condition, rules out possible problems or diseases and makes a diagnosis (Assessment). Finally, the vet prescribes a course of action or treatment (Plan).

Paper-based process

At Vernon Woods Animal Hospital in Sandy Springs, the office practices veterinarian medicine and provides other services such as boarding and grooming. The system is mostly paper-based. Account billing and shot records are automated. Therefore, all animals have a personal medical file that resides in one of several large file cabinets located on a wall of the front office (see Vernon Woods Animal Hospital Floor Plan below). The medical file contains several forms completed by hand. Permanent forms include a white client/patient form with personal and pet information, a blue treatment form outlining past visits and treatments listed by date and a pink form for recording significant events and diagnoses (dog was hit by car, cat has diabetes). However, the pink form is not used regularly because the information is entered on the blue form.

A new blue form is stapled to the file when a previous form is completely full. At each visit, a white procedure/billing form is clipped to the file. The vet circles the various services performed so that the front office knows what to charge the client. Once the client has paid, the white charge form is discarded.

The blue treatment sheet is the most utilized in the file as it contains boarding information, treatment history and diagnoses. Entries begin with the date and are highlighted using coded colors: Pink- shots, Yellow- medications, and Orange- boarding information. Any special information regarding the pet, i.e. dog will bite, is written at the top of the blue sheet.

A typical scenario for Vernon Woods Animal Hospital is as follows:

A client enters the office with her pet. The pet’s medical file is accessed by computer using a customer number. A patient label is printed and adhered to the procedure/billing form. The form is clipped to the file and is placed in the “incoming” window for the vet. A vet is summoned by phone. The client and pet are brought to the exam room. The vet picks up the medical file, reads the blue form for recent treatment history of the pet and enters and exam room. The exam and SOAP process begin. At the end of the exam the vet fills out the blue form, circles procedure(s) performed on the white form, and escorts the client and medical file to the checkout window. The client pays for services rendered. The credit card receipt is stapled to the patient’s medical record. If previous receipts are present, the staple is removed, the new receipt is added to the stack and the receipts are re-stapled to the file.

Movement of the medical file can be traced through the office using the floor plan diagram at the end of this document.

Advantages

A paper-based system does not have the same constraints that a computer-based system would have. The paper medical files are easily portable. There is more flexibility and freedom with data recording since a user is able to write what they feel is necessary to express the problem or event. A computer system may force specific data entry information through the use of data fields. Finally, a paper-based system does not require electricity to function.

Deficiencies

In an office where papers are constantly shuffled, a paper medical file is bound to get lost. There is a large risk of treatment history, diagnoses, etc. getting lost.

The manual process of adding sheets to the file, un-stapling and re-stapling receipts, keeping track of the white charge sheet, etc. is incredibly cumbersome. With a full waiting room, such tasks are inefficient.

When a new blue treatment sheet is added to a file, it is stapled on top of the previous treatment sheets. This means that any special information on previous sheets regarding the dog, i.e. dog will bite, is covered up. Also, the treatment history isn’t very easy to access when the back of the treatment sheet is used. In order to read the back, the paper must be flipped over the top of the file to be read.

Storage space must be ample in order to house all of the files created for every animal.

Shot records are duplicated- shot updates are recorded in the paper medical file and then input into the computer.

It is possible for a pet to be examined by a different vet at each visit. This means that multiple people are entering data into the file. Deciphering handwriting could be a potential problem or even life threatening.

Data searches would be incredibly cumbersome if not impossible. Inventory and accounting reports must be manually performed.

There is not an easy system for cleaning out old or outdated files. To do this in a paper-based system would be highly inefficient and costly. The cost of the amount of paper used plus the cost and time involved with copying is not cost-effective.

Computer-based process

At Veterinarian Medical Clinic in Alpharetta, the entire office is networked. There are 11 dummy stations dispersed through out the office (see VMC Floor Plan Diagram below) that run V/BOSS, proprietary software designed in 1987 especially for veterinarian use. According to Joe Gaston, the owner and a vet at VMC, several different solutions were considered. He thought that V/BOSS was the most robust, meeting the many requirements of his business. At that time, he was told that 130MG would be all he ever needed. He now uses 10 gigabytes, with a database of at least 12,000 clients.

A typical scenario at VMC is as follows:

A client enters the office with her pet. A front office staff member accesses the pet’s medical file and transfers it into WIP (Work In Progress) status. The pet information screen or “cage card” is printed and the client is escorted to an exam room. The door is closed, the cage card is placed into the file holder on the wall and the green marker is raised signaling a vet technician to enter. The vet tech enters with the cage card and begins the subjective portion of SOAP. The vet tech also takes all vitals, gives any shots needed and takes any lab specimen. (The tech may or may not access the patient’s medical record from WIP and enter the vital information.) The tech leaves to perform lab tests, closing the door and raising the red flag signaling the vet. The vet enters and continues with SOAP, reviewing the information already gathered by the tech, assessing the animal’s condition and prescribes treatment and medication. (The tech may return with lab test results and/or prescriptions.) The vet enters all information gathered from each step of SOAP into the medical record. Entries are made as the exam progresses or at the end of the exam. The vet also accesses the patient’s billing screen and enters billing codes. This is usually done using the terminal in the exam room, but it may also be done in the laboratory.

As the tech is performing the lab tests, he or she will also access the client’s billing screen, and enter billing codes for the lab tests performed.

Essentially, it is the responsibility of each vet and tech to access the patient’s record and bill out for test or services performed.

The vet or tech escorts the client and pet to the checkout window and gives the front office staff member the cage card. The front office staff member uses the name on the cage card to access the client’s billing screen and bills out for services rendered.

Advantages

The system supports all of the following:

• Boarding
• Grooming
• Surgery
• Scheduling
• Rolodex
• Employee time reporting
• Payroll
• Accounting
• Patient medical records
• Formulary (drug database similar to PDR)
• Inventory (buy & receive)
• Prescriptions
• Search (by owner first or last name, pet name, account number, breed, diagnosis)

· Several reporting features such as monthly and yearly financial and inventory reporting

The system is extremely robust, supporting all of the above functions. According to Dr. Gaston, VMC utilizes all functionality that the system offers.

The system allows for inventory reporting, sales and services rendered reporting, individual employee sales reporting, prescription label printing (for the prescription bottle), accounts receivable status, and database query for post card mailings.

The interface is also customizable. Screens can be modified depending on the information required by the office.

14 exam templates (annual exam, blood work, etc.) have been created and are accessed by typing in a template code (~###). These are helpful in that a template automatically display the routine input (TEMP [ ], PULSE [ ], etc.) and the user fills in the blank.

Shortcuts can also be created. Shortcuts are accessed by typing a code, .[character(s)] + ENTER. For example, “.Q” + ENTER automatically displays “Please call [DOCTOR’S NAME] with any questions.” A shortcut is made for each employee using his or her initials (.DJG = Doctor Joe Gaston).

Deficiencies

The system is MS-DOS based- all menu functions use the F-# keys. The interface looks similar to the picture below:

Each screen is divided into two or three screen real estate areas, with either the menu at the top, the bottom or both top and bottom of the screen. Reasons for the inconsistency of screen real estate are not known. It could be that some screens require more menu options and need additional space to present all available functions specific to that screen. Regardless, forcing the user to look in two places for functionality is bad usability.

The center "band" of the screen received the most real estate as it contains the most pertinent information regarding client (pet owner) and patient (pet).

The display inconsistently uses a different combination of background and font colors. The background colors are mainly blue or green with white font color or red or yellow with black font color. Any combination of these colors and fonts could be used in the display and are harsh on the eyes. There is also an alert that can be entered in a medical record ("dog will bite", "cat has leukemia") and the background is black with white font. When a screen is displayed with an alert, the alert area flashes.

Menu options are excessive and inconsistent from screen to screen. For example, on one screen, F-9 is used to delete while on another screen; F-9 is used to save. On a third screen, F-9 is used to save and exit.

Some screens have so many menu options that F-10 is designated as an "other" function, allowing completely new menu functions for the same screen. There isn't any feedback to warn the user as to which set of menu functions they are using. So the menu set for F-1 through F-9 can easily be mistaken for the alternate or "other" F-1 through F-9.

The system allows the user to create exam templates. However, in order to make use of them, the user would have to recall the correct code (~###) to access a particular exam template. There is not a logical association between a code and a particular template.

Shortcuts can be helpful, however, in case of the V/BOSS system, it is a problem. Since a code is accessed by .character + ENTER, if the user were to begin typing “.5cc” for a drug prescription, the system recognizes this as a shortcut command. The system then searches its shortcut database but does not find that code. A pop-up window appears stating, “.5cc is not a valid shortcut. Would you like to make it a shortcut?” If the user is not watching as this occurs, he or she will continue typing in the pop-up window, unknowingly creating a new shortcut. Once the new shortcut field is full, it is automatically saved to the system. The next user to type “.5cc” will automatically get the shortcut information accidentally inputted previously.

Certain fields in the medical records do not automatically transfer information to the patient record. Not sure what fields they are…

If the same record is accessed by more than one terminal, the second terminal locks up until the first terminal exits the record. The system also locks up if there are too many records in WIP.

With any computer-based system, there is always the risk of somehow losing all stored information. Dr. Gaston has lost his entire database twice in two months due to lightning strikes and coaxial cable. He said he could have sent the server to California for file retrieval at the cost of $6000.00. He invested in fiber optics instead.

Usability Criteria

The following are the top three criteria our team would like to use in determining the usability of our project.

• Flexibility of input device

As stated above, a vet tech and vet have their hands full during an examination. However, at other times it is possible to use alternative input devices such as a keyboard and mouse or touch screen. We want to incorporate input flexibility.

• Familiarity- the extent to which a user’s knowledge and experience in other real-world or computer-based domains can be applied when interacting with a new system.

Since SOAP is an integral part of the examination, the system would have to support this process. The interface should facilitate this process. Iconography should reflect the artifacts that currently exist in the office. The interface should reflect established metaphors that are standard in office software applications.

• Task Conformance – the degree to which the system services support all of the tasks the user wishes to perform (task completeness) and in the way that the user wishes to perform them (task adequacy).

The system should be robust enough that it allows flexibility in the exam process. With tasks that are shared, the system must permit different approaches from different users at different points in the exam.

Reflections on Requirements Gathering

Our team visited two different vet clinics where we interviewed the targeted users of the system. We were able to speak with three different veterinarians, numerous front office staff members and 1 veterinary technician. In future interviews, we would like to speak with more veterinary technicians and front office staff. In retrospect, we would also like to conduct more in-depth interviews.

From these interviews we gathered that problems exist concerning the way that the information is handled. Examples of the problems that we encountered (or were told about) were that of errors in the recording of information, usability issues with the computer interface, loss of information in the communication process be it by forgetfulness or by mishandling and difficulties with finding appropriate personnel when needed. While we were able to gather a lot of information, it would be nice to return and actually learn to use the computer interface to better identify the usability issues.

Some of the problems encountered were specific to the process. We saw errors of duplication, difficulty in reading the documentation and misplacement of data in the paper-based system. In the computer-based system we saw an interface that was extremely difficult to understand and use efficiently. These problems required that the personnel develop work-arounds to improve the information transfer and communication system and to better the coordination of the office. These conditions create a difficult and lengthy learning curve.

We were prompted to think about the system that we are developing. At the start, we considered developing a new interface for the database system. However, as we conducted interviews, problems surfaced, especially with respect to communication. We envisioned a network of information that would be accessible from anywhere and that would provide data and services more efficiently than the current systems that are in use.

Vernon Woods Animal Hospital Floor Plan Diagram

Veterinary Medial Clinic Floor Plan Diagram