How Regrouping Alerts in Computerized Physician Order Entry Layout Influences Physicians' Prescription Behavior: Results of a Crossover Randomized Trial.

BACKGROUND: As demonstrated in several publications, low positive predictive value alerts in computerized physician order entry (CPOE) induce fatigue and may interrupt physicians unnecessarily during prescription of medication. Although it is difficult to increase the consideration of medical alerts by physician through an improvement of their predictive value, another approach consists to act on the way they are presented. The interruption management model inspired us to propose an alternative alert display strategy of regrouping the alerts in the screen layout, as a possible solution for reducing the interruption in physicians' workflow. OBJECTIVE: In this study, we compared 2 CPOE designs based on a particular alert presentation strategy: one design involved regrouping the alerts in a single place on the screen, and in the other, the alerts were located next to the triggering information. Our objective was to evaluate experimentally whether the new design led to fewer interruptions in workflow and if it affected alert handling. METHODS: The 2 CPOE designs were compared in a controlled crossover randomized trial. All interactions with the system and eye movements were stored for quantitative analysis. RESULTS: The study involved a group of 22 users consisting of physicians and medical students who solved medical scenarios containing prescription tasks. Scenario completion time was shorter when the alerts were regrouped (mean 117.29 seconds, SD 36.68) than when disseminated on the screen (mean 145.58 seconds, SD 75.07; P=.045). Eye tracking revealed that physicians fixated longer on alerts in the classic design (mean 119.71 seconds, SD 76.77) than in the centralized alert design (mean 70.58 seconds, SD 33.53; P=.001). Visual switches between prescription and alert areas, indicating interruption, were reduced with centralized alerts (mean 41.29, SD 21.26) compared with the classic design (mean 57.81, SD 35.97; P=.04). Prescription behavior (ie, prescription changes after alerting), however, did not change significantly between the 2 strategies of display. The After-Scenario Questionnaire (ASQ) that was filled out after each scenario showed that overall satisfaction was significantly rated lower when alerts were regrouped (mean 4.37, SD 1.23) than when displayed next to the triggering information (mean 5.32, SD 0.94; P=.02). CONCLUSIONS: Centralization of alerts in a table might be a way to motivate physicians to manage alerts more actively, in a meaningful way, rather than just being interrupted by them. Our study could not provide clear recommendations yet, but provides objective data through a cognitive psychological approach. Future tests should work on standardized scenarios that would enable to not only measure physicians' behavior (visual fixations and handling of alerts) but also validate those actions using clinical criteria.

Improving Patients Experience in Peadiatric Emergency Waiting Room.

When visiting the emergency department, the perception of the time spent in the waiting room before the beginning of the care, may influence patients' experience. Based on models of service evaluation, highlighting the importance of informing people about their waiting process and their place in the queue, we have developed an innovative information screen aiming at improving perception of time by patients. Following an iterative process, a group of experts including computer scientists, ergonomists and caregivers designed a solution adapted to the pediatric context. The solution includes a screen displaying five lanes representing triage levels. Patients are represented by individual avatars, drawn sequentially in the appropriate line. The interface has been designed using gamification principle, aiming at increasing acceptance, lowering learning curve and improving satisfaction. Questionnaire based evaluation results revealed high satisfaction from the 278 respondents even if the informative content was not always completely clear.

Gesture-Controlled Image Management for Operating Room: A Randomized Crossover Study to Compare Interaction Using Gestures, Mouse, and Third Person Relaying.

OBJECTIVE: In this work, we aim at comparing formally three different interaction modes for image manipulation that are usable in a surgery setting: 1) A gesture-controlled approach using Kinect ®; 2) oral instructions to a third part dedicated to manipulate the images; and 3) direct manipulation using a mouse. MATERIALS AND METHODS: Each participant used the radiology image viewer Weasis with the three interaction modes. In a crossover randomized controlled trial participants were attributed block wise to six experimental groups. For each group, the order for testing the three modes was randomly assigned. Nine standardized scenarios were used. RESULTS: 30 physicians and senior medical students participated in the experiment. Efficiency, measured as time used to pass the scenario, was best when using the mouse (M = 109.10s, SD = 25.96), followed by gesture-controlled (M = 214.97s, SD = 46.29) and oral instructions (M = 246.33s, SD = 76.50). Satisfaction, measured by a questionnaire, was rated highest in the condition mouse (M = 6.63, SD = 0.56), followed by gesture-controlled (M = 5.77, SD = 0.93) and oral instructions (M = 4.40, SD = 1.71). Differences in efficiency and satisfaction rating were significant. No significant difference in effectiveness, measured with error rates, was found. DISCUSSION: The study shows with formal evaluation that the use of gestures is advantageous over instructions to a third person. In particular, the use of gestures is more efficient than verbalizing instructions. The given gestures could be learned easily and reliability of the tested gesture-control system is good. CONCLUSION: Under the premise that mouse cannot be used directly during surgery, gesture-controlled approaches demonstrate to be superior to oral instructions for image manipulation.

Exploring the Challenges and Opportunities of eHealth Tools for Patients with Sickle Cell Disease.

Sickle cell disease (SCD) is the most prevalent inherited blood disorder in the world. The symptoms decrease the quality of life of patients and can cause premature death. Self-help solutions for chronic patients are rising and increase the quality of life of patients. We are interested to identify the usefulness of eHealth tools for patients with SCD. We did a literature review to identify the main problems faced by patients and the existing eHealth solutions. The results show a low number of studies in the field but a multi-disciplinary interest. Positive health benefits for patients are reported as well as the need for more research. Patients and caregivers lack of education about the disease, healthy behaviors are unknown and clinical best practices underused. E-health tools can offer an appropriate support for the self-management of SCD by improving the quality of life of patients, by enhancing patient health literacy and by allowing clinicians to make better decisions.

Use of eye-tracking technology in clinical reasoning: a systematic review.

Achieving a better understanding of the clinical reasoning process is an important approach to improve patient management and patient safety. Although clinical psychologists have used talk-aloud or stimulated recall approaches, these methods have biases. Recently, researchers have been exploring eye-tracking technology to gain "live" insight into clinicians' reasoning processes in certain fields of medicine (radiology, dermatology, etc.). We present a systematic review of eye-tracking literature used for clinical reasoning. We performed a literature search using the terms "eye" or "gaze tracking", "clinical" or "diagnostic reasoning", and "physician" in Pubmed, Embase, Psychinfo, Web of Science and ACM databases. Two investigators screened the abstracts, then full-text articles to select 10 pertinent studies. The studies evaluated medical decision making in four different medical domains using mostly experimental, observational approaches. A total of 208 participants were enrolled for the selected experiments. Paths for further studies are discussed that may extend the use of eye trackers in order to improve understanding of medical decision making.

Online Pharmaceutical Care Provision: Full-Implementation of an eHealth Service Using Design Science Research.

Chronic diseases are pressing health systems to introduce reforms, focused on primary care and multidisciplinary models. Community pharmacists have developed a new role, addressing pharmaceutical care and services. Information systems and technologies (IST) will have an important role in shaping future healthcare provision. However, the best way to design and implement an IST for pharmaceutical service provision is still an open research question. In this paper, we present a possible strategy based on the use of Design Science Research Methodology (DSRM). The application of the DSRM six stages is described, from the definition and characterization of the problem to the evaluation of the artefact.

Reshaping the laboratory results presentation layer: three interfaces for handheld devices.

The interpretation of laboratory results is a critical part of the clinical decision making process. The proper understanding of many clinical conditions depends on the identification of evidences in the laboratory reports. If the classic tabular presentation of laboratory results has demonstrated its efficiency since many years, the increase number of potential results, the increased complexity of cases and the time shortage to analyses cases raise the question of finding more efficient ways of displaying these results to clinicians. The presentation layer becomes even more crucial when it comes to small-sized interactive displays. In this work, we discuss three alternative graphical representations of laboratory results adapted to handheld devices.

Assessing the Usability of Six Data Entry Mobile Interfaces for Caregivers: A Randomized Trial.

BACKGROUND: There is an increased demand in hospitals for tools, such as dedicated mobile device apps, that enable the recording of clinical information in an electronic format at the patient's bedside. Although the human-machine interface design on mobile devices strongly influences the accuracy and effectiveness of data recording, there is still a lack of evidence as to which interface design offers the best guarantee for ease of use and quality of recording. Therefore, interfaces need to be assessed both for usability and reliability because recording errors can seriously impact the overall level of quality of the data and affect the care provided. OBJECTIVE: In this randomized crossover trial, we formally compared 6 handheld device interfaces for both speed of data entry and accuracy of recorded information. Three types of numerical data commonly recorded at the patient's bedside were used to evaluate the interfaces. METHODS: In total, 150 health care professionals from the University Hospitals of Geneva volunteered to record a series of randomly generated data on each of the 6 interfaces provided on a smartphone. The interfaces were presented in a randomized order as part of fully automated data entry scenarios. During the data entry process, accuracy and effectiveness were automatically recorded by the software. RESULTS: Various types of errors occurred, which ranged from 0.7% for the most reliable design to 18.5% for the least reliable one. The length of time needed for data recording ranged from 2.81 sec to 14.68 sec, depending on the interface. The numeric keyboard interface delivered the best performance for pulse data entry with a mean time of 3.08 sec (SD 0.06) and an accuracy of 99.3%. CONCLUSIONS: Our study highlights the critical impact the choice of an interface can have on the quality of recorded data. Selecting an interface should be driven less by the needs of specific end-user groups or the necessity to facilitate the developer's task (eg, by opting for default solutions provided by commercial platforms) than by the level of speed and accuracy an interface can provide for recording information. An important effort must be made to properly validate mobile device interfaces intended for use in the clinical setting. In this regard, our study identified the numeric keyboard, among the proposed designs, as the most accurate interface for entering specific numerical values. This is an important step toward providing clearer guidelines on which interface to choose for the appropriate use of handheld device interfaces in the health care setting.

Physician handoffs: opportunities and limitations for supportive technologies.

Shift-to-shift handoffs refer to the process of transferring role and responsibility for providing care from one person to another, thus insuring continuity of care. Through focus groups of residents and supervising physicians, we studied how physicians select patient cases to discuss during handoffs. We also compared the selection across level of experience. Understanding the patient selection criteria can give us insight into how to improve handoffs, in particular using supportive technologies that are integrated into the clinical information system. Studying the actual handoff process and note-taking also generated suggestions for handoff improvement.

User acquaintance with mobile interfaces.

Handheld technology finds slowly its place in the healthcare world. Some clinicians already use intensively dedicated mobile applications to consult clinical references. However, handheld technology hasn't still broadly embraced to the core of the healthcare business, the hospitals. The weak penetration of handheld technology in the hospitals can be partly explained by the caution of stakeholders that must be convinced about the efficiency of these tools before going forward. In a domain where temporal constraints are increasingly strong, caregivers cannot loose time on playing with gadgets. All users are not comfortable with tactile manipulations and the lack of dedicated peripheral complicates entering data for novices. Stakeholders must be convinced that caregivers will be able to master handheld devices. In this paper, we make the assumption that the proper design of an interface may influence users' performances to record information. We are also interested to find out whether users increase their efficiency when using handheld tools repeatedly. To answer these questions, we have set up a field study to compare users' performances on three different user interfaces while recording vital signs. Some user interfaces were familiar to users, and others were totally innovative. Results showed that users' familiarity with smartphone influences their performances and that users improve their performances by repeating a task.

Assisted knowledge discovery for the maintenance of clinical guidelines.

BACKGROUND: Improving antibiotic prescribing practices is an important public-health priority given the widespread antimicrobial resistance. Establishing clinical practice guidelines is crucial to this effort, but their development is a complex task and their quality is directly related to the methodology and source of knowledge used. OBJECTIVE: We present the design and the evaluation of a tool (KART) that aims to facilitate the creation and maintenance of clinical practice guidelines based on information retrieval techniques. METHODS: KART consists of three main modules 1) a literature-based medical knowledge extraction module, which is built upon a specialized question-answering engine; 2) a module to normalize clinical recommendations based on automatic text categorizers; and 3) a module to manage clinical knowledge, which formalizes and stores clinical recommendations for further use. The evaluation of the usability and utility of KART followed the methodology of the cognitive walkthrough. RESULTS: KART was designed and implemented as a standalone web application. The quantitative evaluation of the medical knowledge extraction module showed that 53% of the clinical recommendations generated by KART are consistent with existing clinical guidelines. The user-based evaluation confirmed this result by showing that KART was able to find a relevant antibiotic for half of the clinical scenarios tested. The automatic normalization of the recommendation produced mixed results among end-users. CONCLUSIONS: We have developed an innovative approach for the process of clinical guidelines development and maintenance in a context where available knowledge is increasing at a rate that cannot be sustained by humans. In contrast to existing knowledge authoring tools, KART not only provides assistance to normalize, formalize and store clinical recommendations, but also aims to facilitate knowledge building.

Challenges in the Implementation of a Mobile Application in Clinical Practice: Case Study in the Context of an Application that Manages the Daily Interventions of Nurses.

BACKGROUND: Working in a clinical environment requires unfettered mobility. This is especially true for nurses who are always on the move providing patients' care in different locations. Since the introduction of clinical information systems in hospitals, this mobility has often been considered hampered by interactions with computers. The popularity of personal mobile assistants such as smartphones makes it possible to gain easy access to clinical data anywhere. OBJECTIVE: To identify the challenges involved in the deployment of clinical applications on handheld devices and to share our solutions to these problems. METHODS: A team of experts underwent an iterative development process of a mobile application prototype that aimed to improve the mobility of nurses during their daily clinical activities. Through the process, challenges inherent to mobile platforms have emerged. These issues have been classified, focusing on factors related to ensuring information safety and quality, as well as pleasant and efficient user experiences. RESULTS: The team identified five main challenges related to the deployment of clinical mobile applications and presents solutions to overcome each of them: (1) Financial: Equipping every care giver with a new mobile device requires substantial investment that can be lowered if users use their personal device instead, (2) Hardware: The constraints inherent to the clinical environment made us choose the mobile device with the best tradeoff between size and portability, (3) Communication: the connection of the mobile application with any existing clinical information systems (CIS) is insured by a bridge formatting the information appropriately, (4) Security: In order to guarantee the confidentiality and safety of the data, the amount of data stored on the device is minimized, and (5) User interface: The design of our user interface relied on homogeneity, hierarchy, and indexicality principles to prevent an increase in data acquisition errors. CONCLUSIONS: The introduction of nomadic computing often raises enthusiastic reactions from users, but several challenges due to specific constraints of mobile platforms must be overcome. The ease of development of mobile applications and their rapid spread should not overshadow the real challenges of clinical applications and the potential threats for patient safety and the liability of people and organizations using them. For example, careful attention must be given to the overall architecture of the system and to user interfaces. If these precautions are not taken, it can easily lead to unexpected failures such as an increased number of input errors, loss of data, or decreased efficiency.

INCA - Individual Nomad Clinical Assistant - supporting nurses with mobile devices.

INTRODUCTION: A completely structured nursing record has been deployed in the 8 hospitals of the University hospitals of Geneva. Even with laptops, the access to the records restrains nurses' mobility during their bedside work. It has lead to a strong demand for mobile devices. PROBLEM: There are several papers showing that mobile computers can lead to increase time for data acquisition, increased errors and omissions. Thus, there are important challenges at developing these tools, while respecting the mobile paradigm and the needs for qualitative and efficient acquisition. A simple translation of user interfaces from usual computers is not recommended. RESULTS: After evaluating various user interfaces with users in real conditions, we propose a solution that eases the selection of patients, the navigation into the various screens, and provides a very clear list of tasks to achieve for nurses. CONCLUSION: The article exposes the difficulties to adapt an existing tool on mobile devices. Despite these difficulties, by organizing smartly the displayed information, we produced a tool with similar functionalities but better adapted to the user.

A qualitative analysis of prescription activity and alert usage in a computerized physician order entry system.

Medical alerts in CPOE are overridden in most cases. The need for alerting systems that are better adapted to physicians' needs and work processes is recognized. Our study aims to shed some light on how medical alerts are used and how they are integrated in the work process. Work analysis and interviews resulted in a hierarchical task analysis of prescription during ward rounds at the University Hospitals of Geneva. The results indicate that non-modal medical alerts are appreciated as an "insurance" for drugs that are out of the routine set. In the case of drugs that are often prescribed, alerts are ignored as physicians feel comfortable prescribing them. Non-interrupting alerts do not cognitively overcharge physicians, but the question is how to display the numerous alerts so that they are easily accessible when needed. Further, inexperienced physicians lack a mental representation of what evaluations the system is doing with the prescriptions and when alerts are triggered. This may lead to lack of trust or overconfidence, both of them potentially harmful.

Alerts in clinical information systems: building frameworks and prototypes.

Alerts in Clinical Information Systems and CPOE are powerful tools for decision support. However, studies show that physicians override a large part of these alerts. Low specificity and high bandwidth of alerts lead to alert fatigue. Moreover, alerts seem to have usability issues as they are interrupting workflows and not always efficient to handle. This paper provides three different views on alerts: a system-based view, a human-computer interaction view and an organizational view. Based on this framework, we present a prototype of alert handling, which might ameliorate some of the problems with alerts.