Faculty Bibliography

BACKGROUND:Design thinking and human-centered design approaches have become increasingly common in health care literature, particularly in relation to health information technology (HIT), as a pathway toward the development of usable, diffusible tools and processes. There is a need in academic medical centers tasked with digital innovation for a comprehensive process model to guide development that incorporates current industry trends, including design thinking and lean and agile approaches to digital development. OBJECTIVE:This study aims to describe the foundations and phases of our model for user-centered HIT development. METHODS:Based on our experience, we established an integrated approach and rigorous process for HIT development that leverages design thinking and lean and agile strategies in a pragmatic way while preserving methodological integrity in support of academic research goals. RESULTS:A four-phased pragmatic process model was developed for user-centered digital development in HIT. CONCLUSIONS:The model for user-centered HIT development that we developed is the culmination of diverse innovation projects and represents a multiphased, high-fidelity process for making more creative, flexible, efficient, and effective tools. This model is a critical step in building a rigorous approach to HIT design that incorporates a multidisciplinary, pragmatic perspective combined with academic research practices and state-of-the-art approaches to digital product development to meet the unique needs of health care.

We integrated and optimized patient-reported outcome measures into the electronic health record to provide quantitative, objective data regarding patients' health status, which is important for patient care, payer contracts, and research. With a multidisciplinary team from information technology, clinical informatics, population health, and physician champions, we used formal human-computer interaction techniques and user-centered design to integrate several technology platforms and computerized adaptive testing for the National Institutes of Health Patient-Reported Outcomes Measurement Information System. The patient-reported outcome measure system leverages software frequently used by health systems and provides data for research and clinical care via a mobile-responsive web application using Symfony, with REDCap for configuring assessments and de-identified data storage. The system incorporates Oracle databases and Epic flowsheets. Patients complete patient-reported outcome measures, with data viewable in MyChart and Epic Synopsis Reports. Researchers can access data portals. The highly usable, successful patient-reported outcome measures platform is acceptable to patients and clinicians and achieved 73 percent overall completion rates.

BACKGROUND:Technology is increasingly embedded into the full spectrum of health care. This movement has benefited from the application of software development practices such as usability testing and agile development processes. These practices are frequently applied in both commercial or operational and academic settings. However, the relative importance placed on rapid iteration, validity, reproducibility, generalizability, and efficiency differs between the 2 settings and the needs and objectives of academic versus pragmatic usability evaluations. OBJECTIVE:This paper explores how usability evaluation typically varies on key dimensions in pragmatic versus academic settings that impact the rapidity, validity, and reproducibility of findings and proposes a hybrid approach aimed at satisfying both pragmatic and academic objectives. METHODS:We outline the characteristics of pragmatic versus academically oriented usability testing in health care, describe the tensions and gaps resulting from differing contexts and goals, and present a model of this hybrid process along with 2 case studies of digital development projects in which we demonstrate this integrated approach to usability evaluation. RESULTS:The case studies presented illustrate design choices characteristic of our hybrid approach to usability evaluation. CONCLUSIONS:Designed to leverage the strengths of both pragmatically and academically focused usability studies, a hybrid approach allows new development projects to efficiently iterate and optimize from usability data as well as preserves the ability of these projects to produce deeper insights via thorough qualitative analysis to inform further tool development and usability research by way of academically focused dissemination.

Background: Clinical decision support (CDS) has been shown to im-prove compliance with evidence-based care but its impact is often diminished due to issues such as poor usability, insufficient integration into workflow, and alert fatigue. Non-interruptive CDS may be less subject to alert fatigue but there has been little assessment of its usability. The purpose of this study was to perform usability testing on interruptive and non-interruptive versions of a CDS. Methods: We conducted a usability study ofa CDS tool that recommended prescribing an angiotensin converting enzyme (ACE) inhibitor for inpatients with heart failure. We developed two versions of the CDS that varied in its format: an interruptive alert, in which the CDS popped-up at the time of order entry, and a non-interruptive alert, which was displayed in a checklist section of the Electronic Health Record (EHR). We recruited inpatient providers to use both versions in a laboratory setting. We randomly assigned providers to first trigger the interruptive or non-interruptive alert. Providers were given a clinical scenario and asked to " think aloud" as they worked through the CDS; we then conducted a brief semi-structured interview about usability. We used a constant comparative analysis informed by the Five Rights of CDS framework to analyze the interviews. Inpatient providers from different disciplines were recruited until thematic saturation was reached. Results: Of 12 providers who participated in usability testing, seven used the interruptive followed by the non-interruptive CDS and five used the non-interruptive CDS initially. We categorized codes into four themes related to the Five Rights of CDS and determined some codes to be general to the CDS while others were specific to the interruptive or non-interruptive version (Table). Providers noted that the interruptive alert was readily noticed but generally impeded workflow. Providers found the non-interruptive CDS to be less annoying but had lower visibility; although they liked the ability to address the non-interruptive CDS at any time, some providers questioned whether it would ultimately be used. Conclusions: Providers expressed annoyance in working with an inter-ruptive CDS. Although the non-interruptive CDS was more appealing, providers admitted that it may not be used unless integrated with workflow. One potential solution was a combination of the two formats: supplementing a non-interruptive alert with an occasional, well-timed interruptive alert if uptake was insufficient

Background: The potential of the electronic health record (EHR) and clinical decision support (CDS) to improve the practice of medicine have been significantly tempered by poor design and the resulting burden they place on health care providers. CDS is rarely tested in the real clinical environment. As a result many tools are hard to use, placing strain on providers and resulting in low adoption rates. This is the first study to evaluate CDS usability and the provider-computer-patient interaction in the real clinical environment. The objective of this study was to further understand barriers and facilitators of meaningful CDS usage within a real clinical context. Methods: This qualitative observational study was conducted with three primary care providers during a total of six patient care sessions. In patients with the chief complaint of sore throat the Centor Score was used to stratify the risk of group A strep pharyngitis. In patients with a chief complaint of cough or upper respiratory infection the Heckerling Rule was used to stratify the risk of pneumonia. During usability testing all human-computer interactions, including audio and continuous screen capture, were recorded using Camtasia software. Participants' comments and interactions with the tool during patient care sessions and participant comments during a post-session brief interview were placed into coding categories and analyzed for generalizable themes. Results: In the 6 encounters observed, primary care providers toggled between addressing either the computer or the patient during the visit. Minimal time was spent listening to the patient without engaging the EHR. Participants almost always used the CDS tool with the patient, asking questions to populate the calculator and discussing the results of the risk assessment; they reported the ability to do this as the major benefit of the tool. All primary care providers were interrupted during their use of the CDS tool by the need to refer to other sections of the chart. In half of the visits, patient's clinical symptoms challenged the applicability of the clinical prediction rule to calculate the risk of bacterial infection. Primary care providers rarely used the incorporated incentives for CDS usage, including progress notes and patient instructions/documentation. Conclusions: Live usability testing of these CDS tools generated insights about their role in the patient-provider interaction. CDS may contribute to the interaction by being simultaneously viewed by provider and patient. CDS can improve usability and lessen the strain it places on providers by being short, flexible and customizable to unique provider workflow. A useful component of CDS is being as widely applicable as possible and ensuring that its functions represent the fastest way to perform a particular task