Estimating Cognitive Load in a Mobile Personal Health Record Application: A Cognitive Task Analysis Approach.

OBJECTIVES: Mobile health applications that are designed without considering usability criteria can lead to cognitive overload, resulting in the rejection of these apps. To avoid this problem, the user interface of mobile health applications should be evaluated for cognitive load. This evaluation can contribute to the improvement of the user interface and help prevent cognitive overload for the user. METHODS: In this study, we evaluated a mobile personal health records application using the cognitive task analysis method, specifically the goals, operators, methods, and selection rules (GOMS) approach, along with the related updated GOMS model and gesture-level model techniques. The GOMS method allowed us to determine the steps of the tasks and categorize them as physical or cognitive tasks. We then estimated the completion times of these tasks using the updated GOMS model and gesture-level model. RESULTS: All 10 identified tasks were split into 398 steps consisting of mental and physical operators. The time to complete all the tasks was 5.70 minutes and 5.45 minutes according to the updated GOMS model and gesture-level model, respectively. Mental operators covered 73% of the total fulfillment time of the tasks according to the updated GOMS model and 76% according to the gesture-level model. The inter-rater reliability analysis yielded an average of 0.80, indicating good reliability for the evaluation method. CONCLUSIONS: The majority of the task execution times comprised mental operators, suggesting that the cognitive load on users is high. To enhance the application's implementation, the number of mental operators should be reduced.

Development and refinement of a novel end-of-life planning website for patients with advanced cancer: a mixed methods approach.

PURPOSE: Despite known benefits of planning for end-of-life, no digital tool exists to help patients with advanced cancer and their loved ones plan for death comprehensively. To address this unmet need, we developed a preliminary version of an innovative website to help patients with advanced cancer prepare for end-of-life tasks. METHODS: Guided by the Obesity-Related Behavioral Intervention Trials (ORBIT) model for behavioral intervention development, patients with advanced cancer (n = 10) and their caregivers (n = 10) participated in a "Think Aloud" exercise and usability protocols to optimize the end-of-life planning website. The website was iteratively refined throughout the study in collaboration with the partnering company, Peacefully, Inc. Participants also completed the Acceptability E-Scale and System Usability Scale, with a priori benchmarks established for acceptability (scores of ≥ 24 on the Acceptability E-Scale) and usability (scores of ≥ 68 on the System Usability Scale). RESULTS: Patients (N = 10) and caregivers (N = 10) completed usability testing. Patients were majority female (80%), White (100%), and had a mean age of 58 years. Caregivers (N = 10) were majority male (60%), spouse/partner (90%), White (90%), and had a mean age of 59 years. For patients, a priori hypotheses were met for both acceptability (mean score of 24.7, SD = 4.35) and usability (mean score of 73.8, SD = 6.15). For caregivers, acceptability was just below the cutoff (mean score of 22.9, SD = 4.07) and usability exceeded the cutoff (mean score of 70.0, SD = 8.42). Overall, patients and caregivers reported high levels of satisfaction and found the website helpful, with specific suggestions for changes (e.g., add more information about information security, improve text legibility). CONCLUSIONS: The findings from this study will inform modifications to optimize an innovative website to support patients with advanced cancer to prepare holistically for end-of-life tasks.

An exploration of facilitators and barriers to patient navigator core functions with breast cancer patients: Implications for the development of a human-centered mHealth app.

Objectives: To understand the barriers to core functions and workflow among patient navigators (PN) who navigate people diagnosed with breast cancer (BC). To identify how a mobile health (mHealth) app could assist PNs in providing care to BC patients. Methods: This qualitative research study used purposive sampling to recruit stakeholders (N = 33) from January to August 2021. We conducted individual semi-structured interviews with PNs (n = 11), oncology care providers (n = 12), and BC patients (n = 10). We used conventional content analysis to analyze the interview data. Results: Participants identified the following sociotechnical systems barriers in PN workflows that negatively impact BC patient care: 1) resources, 2) insurance coverage, 3) communication challenges, and 4) impact of logistical tasks. Participants identified the user experience, app features, and interoperability customizations to enhance PNs' provision of patient care as important design elements to include in a mHealth app. Conclusion: Feedback from stakeholders provided valuable insights into key design considerations, functions, and content areas for developing a mHealth app for PN use in BC care delivery. Innovation: This is one of the first studies to incorporate the human-centered design and sociotechnical systems frameworks to understand barriers to PN workflow and provision of BC patient care across the cancer care continuum.

Utility of an endoscopic image processing system for framing laparoscopic images using surgeon's gaze point and voice commands during laparoscopic percutaneous extraperitoneal closure of inguinal hernia in children.

Introduction: In laparoscopic surgery, it is the assistant who manipulates the laparoscope and manages the field of view. Aim: To develop an endoscopic image processing system that can adjust laparoscopic images as intended by the surgeon without interrupting the surgical procedure. Material and methods: We developed a touchless user interface that displays a magnified image of the endoscope using information of the surgeon's gaze point acquired by an eye-tracking device and the surgeon's voice commands, and evaluated its usefulness during laparoscopic percutaneous extraperitoneal closure (LPEC) of pediatric inguinal hernia. Results: LPEC was performed in 15 clinical cases of pediatric inguinal hernia using this system. In all cases, the internal inguinal ring could be ligated by digitally zooming and moving the endoscopic image by eye tracking and voice command while the scope was fixed. Conclusions: This new touchless user interface with eye tracking shows promise as a support system for laparoscopic surgery.

FHIR DataProvider for ReactAdmin: Leveraging User Interface Creation for Medical Web Applications.

In medical data science, FHIR provides an increasingly used information model, which will lead to the creation of FHIR warehouses in the future. To efficiently work with a FHIR-based representation, users need a visual representation. The modern UI framework ReactAdmin (RA) enhances usability by leveraging current web standards such as React and Material Design. Rapid development and implementation of usable modern UIs is made possible by its high modularity and many widgets available in the framework. For data connection to different data sources RA needs a DataProvider (DP), which maps the communication from the server to the provided components. In this work, we present a DataProvider for FHIR that enables future UI developments for FHIR servers using RA. A demo application demonstrates the DP's capabilities. The code is published under MIT license.

Holistic Digitalization of the Nursing Internship Process in the Federal State of Salzburg with Strong User Involvement.

BACKGROUND: In the federal state of Salzburg, the harmonization of nursing internship took place from 2014-2019 as a joint effort of educational and internship providers. Currently the handling of these mostly paper pencil-based documents involves a manual process through different institutions and people. OBJECTIVES: The project provides the basis for the implementation of the "internship platform". In the future, this is to be the digital, state-of-the-art one-stop shop for the state-wide practical nursing training (in the form of immanent internships) at all training levels. METHODS: The process is influenced by modern requirements engineering techniques: As-is analysis of the internship process and related documents, contextual inquires in different internship providers, iterative focus group discussions focusing first on user stories, then on interface designs, and final user testing. RESULTS: Standardized workflow and authorization concept for all user groups, mandatory requirements for the software system, tested user interfaces, tender documents for EU-wide tender procedure. CONCLUSION: Positive feedback from all involved user groups on project goal, results and involvement in the process.

Designing an app for alternative access assessments: using interviews to uncover and define user needs.

To support effective alternative access assessment and service delivery for people with motor impairments, we are developing an app called Access Navigator. This paper describes the first stage of the project: the interviews we conducted as part of a discovery process to improve our understanding of user needs. We individually interviewed 8 assistive technology practitioners and 3 clients who use alternative access methods, to learn what practitioners were currently doing in their access assessments, identify opportunities for improving current practice, and understand what the assessment process was like for clients. We extracted 236 relevant quotes from interview transcripts, and clustered the quotes using the affinity wall method, yielding 42 themes. Here we present the 21 highest priority themes, along with the app requirements that support those themes. Results confirmed the need for a tool to support more effective assessments, with emphasis on taking the worry out of access assessments and supporting early success. Results also revealed specific needs such as flexible workflow, personalized test-drive tasks, and a choice of metrics (including client preference). With a richer understanding of user needs, we are in a much better position to design software that can address those needs.

Development of an Open-Source Injection Mold Monitoring System.

In the highly competitive injection molding industry, the ability to effectively collect information from various sensors installed in molds and machines is of the utmost relevance, enabling the development of data-based Industry 4.0 algorithms. In this work, an alternative to commercially available monitoring systems used in the industry was developed and tested in the scope of the TOOLING 4G project. The novelty of this system is its affordability, simplicity, real-time data acquisition and display in an intuitive Graphical User Interface (GUI), while being open-source firmware and software-based. These characteristics, and their combinations have been present in previous works, but, to the authors' knowledge, not all of them simultaneously. The system used an Arduino microcontroller-based data acquisition module that can be connected to any computer via a USB port. Software was developed, including a GUI, prepared to receive data from both the Arduino module and a second module. In the current state of development, data corresponding to a maximum of six sensors can be visualized, at a rate of 10 Hz, and recorded for later usage. These capabilities were verified under real-world conditions for monitoring an injection mold with the objective of creating the basis of a platform to deploy predictive maintenance. Mold temperature, cavity pressure, 3-axis acceleration, and extraction force data showed the system can successfully monitor the mold and allowed the clear distinction between normal and abnormal operating patterns.

Postmenopausal women's cognitive function and performance of virtual reality tasks.

OBJECTIVE: This study aimed to assess whether prior knowledge of computer use determines performance of virtual reality tasks by postmenopausal women and whether menopausal symptoms, sociodemographic factors, lifestyle and cognition modify or interfere with their performance. METHOD: This cross-sectional study included 152 postmenopausal women divided into two groups: computer users and non-users. Age, ethnicity, time of menopause, menopausal symptoms, female health status, level of physical activity and cognitive function were considered. The participants played a virtual reality game and were assessed for hits, errors, omissions and game time. The Mann-Whitney, chi-square and Fisher exact tests and multivariate linear regression analysis were used. RESULTS: Postmenopausal computer users play virtual reality games (p = 0.005) better than postmenopausal non-users of computers. Vasomotor symptoms were high in women who used computers compared to those who did not (p = 0.006). Multivariate linear regression analysis found that the best-fitting predictors for the number of hits - that is, age (p = 0.039), Mini-Mental State Examination score (p = 0.006) and the headache symptom (p = 0.021) - influence the performance of virtual reality tasks. CONCLUSION: Computer users performed virtual reality tasks better than non-users. Headache and age but not vasomotor symptoms negatively affected the postmenopausal women's performance.

Problem-oriented documentation: design and widespread adoption of a novel toolkit in a commercial electronic health record.

Background: Problem-oriented documentation is an accepted method of note construction which facilitates clinical thought processes. However, problem-oriented documentation is challenging to put into practice using commercially available electronic health record (EHR) systems. Objective: Our goal was to create, iterate, and distribute a problem-oriented documentation toolkit within a commercial EHR that maximally supported clinicians' thinking, was intuitive to use, and produced clear documentation. Materials and Methods: We used an iterative design process that stressed visual simplicity, data integration, a predictable interface, data reuse, and clinician efficiency. Creation of the problem-oriented documentation toolkit required the use of EHR-provided tools and custom programming. Results: We developed a problem-oriented documentation interface with a 3-column view showing (1) a list of visit diagnoses, (2) the current overview and assessment and plan for a selected diagnosis, and (3) a list of medications, labs, data, and orders relevant to that diagnosis. We also created a series of macros to bring information collected through the interface into clinicians' notes. This toolkit was put into a live environment in February 2019. Over the first 9 months, the custom problem-oriented documentation toolkit was used in a total of 8385 discrete visits by 28 clinicians in 13 ambulatory departments. After 9 months, the go-live education and EHR optimization teams in our health system began promoting the toolkit to new and existing users of our EHR resulting in a significantly increased uptake by outpatient clinicians. In April 2022 alone, the toolkit was used in more than 92 000 ambulatory visits by 894 users in 271 departments across our health system. Conclusions: As a health-system client of a commercial EHR, we developed and deployed a revised problem-oriented documentation toolkit that is used by clinicians more than 92 000 times a month. Key success elements include an emphasis on usability and an effective training effort.

DentaSeal: A school-based dental sealant efficiency assessment tool to support statewide monitoring and reporting: A field report.

BACKGROUND: The evidence base supports effectiveness of dental sealants for prevention of childhood caries in school-aged children. OBJECTIVE: This study describes planning, development, usability testing and outcomes following implementation of DentaSeal, a web-based application designed to accurately track unique student data and generate reports for all Wisconsin school-based sealant placement (SP) programs. METHODS: Application software development was informed by a steering committee of representative stakeholders who were interviewed to inform design and provide feedback for design of DentaSeal during development and evaluation. Software development proceeded based on wireframes developed to build architectural design. Usability testing followed and informed any required adjustments to the application. The DentaSeal prototype was beta tested and fully implemented subsequently in the public health sector. RESULTS: The DentaSeal application demonstrated capacity to: 1) track unique student SP data and longitudinal encounter history, 2) generate reports and 3) support administrative tracking. In 2019, DentaSeal captured SP data of 47 school-based programs in Wisconsin that sponsored > 7,000 program visits for 184,000 children from 62 counties. Delivery of > 548,000 SP services were catalogued. CONCLUSIONS: For public health initiatives targeting reduction in caries incidence, web-based applications such as DentaSeal represent useful longitudinal tracking tools for cataloguing SP in school-based program participants.

Developing a Technical-Oriented Taxonomy to Define Archetypes of Conversational Agents in Health Care: Literature Review and Cluster Analysis.

BACKGROUND: The evolution of artificial intelligence and natural language processing generates new opportunities for conversational agents (CAs) that communicate and interact with individuals. In the health domain, CAs became popular as they allow for simulating the real-life experience in a health care setting, which is the conversation with a physician. However, it is still unclear which technical archetypes of health CAs can be distinguished. Such technical archetypes are required, among other things, for harmonizing evaluation metrics or describing the landscape of health CAs. OBJECTIVE: The objective of this work was to develop a technical-oriented taxonomy for health CAs and characterize archetypes of health CAs based on their technical characteristics. METHODS: We developed a taxonomy of technical characteristics for health CAs based on scientific literature and empirical data and by applying a taxonomy development framework. To demonstrate the applicability of the taxonomy, we analyzed the landscape of health CAs of the last years based on a literature review. To form technical design archetypes of health CAs, we applied a k-means clustering method. RESULTS: Our taxonomy comprises 18 unique dimensions corresponding to 4 perspectives of technical characteristics (setting, data processing, interaction, and agent appearance). Each dimension consists of 2 to 5 characteristics. The taxonomy was validated based on 173 unique health CAs that were identified out of 1671 initially retrieved publications. The 173 CAs were clustered into 4 distinctive archetypes: a text-based ad hoc supporter; a multilingual, hybrid ad hoc supporter; a hybrid, single-language temporary advisor; and, finally, an embodied temporary advisor, rule based with hybrid input and output options. CONCLUSIONS: From the cluster analysis, we learned that the time dimension is important from a technical perspective to distinguish health CA archetypes. Moreover, we were able to identify additional distinctive, dominant characteristics that are relevant when evaluating health-related CAs (eg, input and output options or the complexity of the CA personality). Our archetypes reflect the current landscape of health CAs, which is characterized by rule based, simple systems in terms of CA personality and interaction. With an increase in research interest in this field, we expect that more complex systems will arise. The archetype-building process should be repeated after some time to check whether new design archetypes emerge.

The use of a novel sensorized simulation platform for real-time labor progression assessment.

OBJECTIVE: To prove the potentialities of an integrated and sensorized childbirth platform as an innovative simulator for education of inexperienced gynecological and obstetrical medical students. METHODS: A total of 152 inexperienced medical students were recruited to a simulation program on labor progression evaluation. After an introductory lecture on basic concepts of labor and birth given by an expert gynecologist, three different gynecologic scenarios were simulated using both a traditional obstetric simulator and the innovative proposed platform, for a total of six tests for each student. A score was assigned for each performed scenario, based on its correctness. Self-assessment questionnaires were compiled before and after the simulation program for additional subjective assessment. RESULTS: Median score of the simulations performed with our platform was significantly higher than that of the simulations performed with a traditional simulator, for all the three experimented scenarios (P < 0.001). CONCLUSIONS: The use of a sensorized platform for labor progression allowed for an accurate and faster diagnosis if compared with a traditional simulator even for inexperienced operators, supporting its use in clinical training, which could be realistically introduced into the clinical practice for medical student education.

Web version of the protocol of the orofacial myofunctional evaluation with scores: usability and learning / Versão para Web do protocolo de avaliação miofuncional com escores: usabilidade e aprendizado

ABSTRACT Purpose The Orofacial Myofunctional Evaluation with Scores (OMES) protocol has been validated and used in clinical practice and research. The goals of this study were to develop, analyze and improve a version of OMES for the Web and to investigate the relationship between the usability judgments and the prior experience of the evaluators and whether using the interface promotes learning, as shown by the task completion time (TCT). Methods Study steps: 1) inspection of the prototype by the team; 2) evaluation of usability by three experienced speech-language pathologists (SLPs); and 3) evaluation of its usability by 12 SLPs with varying levels of experience in the use of OMES. Participants answered the Heuristic evaluation (HE), the Computer System Usability Questionnaire (CSUQ), and expressed free comments. The TCT was recorded. Results The OMES-Web reached excellent usability levels, and the participants were highly satisfied. The correlations between the participants' experience and the HE and CSUQ scores were not significant. The TCT decreased significantly throughout the tasks. Conclusion OMES-Web meets the usability criteria, and participants feel satisfied with the system regardless of their level of experience. The fact that it is easy to learn favors its adoption by professionals.

RESUMO Objetivo O Protocolo de Avaliação Miofuncional Orofacial com Escores (AMIOFE) é validado e usado na prática clínica e pesquisas. Os objetivos deste estudo foram desenvolver, analisar e aprimorar a versão do AMIOFE para a Web e investigar a relação entre os julgamentos de usabilidade e a prévia experiência dos avaliadores, e se o manuseio da interface promove o aprendizado, baseado no tempo para completar a tarefa (TCT). Método Passos do estudo: 1) inspeção do protótipo pela equipe; 2) avaliação de usabilidade por três fonoaudiólogos experientes; e 3) avaliação de usabilidade por 12 fonoaudiólogos com variados níveis de experiência no uso do AMIOFE. Avaliação heurística (HE), Computer System Usability Questionnaire (CSUQ) e livre expressão dos participantes foram realizadas. O TCT foi registrado. Resultados O AMIOFE-Web atingiu ótimos níveis de usabilidade e os participantes mostram-se altamente satisfeitos (Escala geral do CSUQ; Média= 1,31, DP= 0,31). A relação da experiência dos participantes e a HE e o CSUQ não foi significativa. O TCT decresceu significantemente ao longo das tarefas, mostrando que o sistema é fácil de aprender e usar. Conclusão O AMIOFE-Web atende os critérios de usabilidade e os participantes sentiram-se satisfeitos com o sistema, independentemente de seus níveis de experiência. O fato de ser de fácil aprendizado é um fator favorável para a sua adoção por profissionais.

Using motion capture technology to assess locomotor development in children.

Objective: Motor and cognitive development share biological background within the prefrontal cortex and cerebellum. Monitoring motor development is relevant to identify children at risk of developmental delays. However, access to timely assessment is prevented by its availability and cost. Affordable motion capture technology may provide an alternative to human assessment. Methods: MotorSense uses this technology to guide and assess children executing age-related developmental motor tasks. It incorporates advanced heuristics informed by pattern recognition principles based on the developmental sequences of motor skills. MotorSense was evaluated with 16 4-6 year-old children from a rural primary school. Results: A total of 506 jumps, 2415 steps and 831 hops were analysed. The analysis illustrates MotorSense Accuracy (MA), recognising jump forward (89.96%), jump high (83.34%), jump sideway (85.63%), hop (74.58%) and jog (92.34%), is as good as the sensor's precision. The analysis of the tasks' execution shows a high level of agreement between human and MotorSense's assessment on jump forward (91%), jump high (99%), jump sideway (93%), hop (94%) and jog (92%). Conclusions: MotorSense helps address the shortage of affordable technologies to support the assessment of motor development using graded age-related developmental motor tasks. Furthermore, it could contribute towards the tele-detection of motor developmental delays.

Development of pre-procedure virtual simulation for challenging interventional procedures: an experimental study with clinical application.

Background: Most pain management techniques for challenging procedures are still performed under the guidance of the C-arm fluoroscope although it is sometimes difficult for even experienced clinicians to understand the modified three-dimensional anatomy as a two-dimensional X-ray image. To overcome these difficulties, the development of a virtual simulator may be helpful. Therefore, in this study, the authors developed a virtual simulator and presented its clinical application cases. Methods: We developed a computer program to simulate the actual environment of the procedure. Computed tomography (CT) Digital Imaging and Communications in Medicine (DICOM) data were used for the simulations. Virtual needle placement was simulated at the most appropriate position for a successful block. Using a virtual C-arm, the authors searched for the position of the C-arm at which the needle was visualized as a point. The positional relationships between the anatomy of the patient and the needle were identified. Results: For the simulations, the CT DICOM data of patients who visited the outpatient clinic was used. When the patients revisited the clinic, images similar to the simulated images were obtained by manipulating the C-arm. Transforaminal epidural injection, which was difficult to perform due to severe spinal deformity, and the challenging procedures of the superior hypogastric plexus block and Gasserian ganglion block, were successfully performed with the help of the simulation. Conclusions: We created a pre-procedural virtual simulation and demonstrated its successful application in patients who are expected to undergo challenging procedures.

DQAgui: a graphical user interface for the MIRACUM data quality assessment tool.

BACKGROUND: With the growing impact of observational research studies, there is also a growing focus on data quality (DQ). As opposed to experimental study designs, observational research studies are performed using data mostly collected in a non-research context (secondary use). Depending on the number of data elements to be analyzed, DQ reports of data stored within research networks can grow very large. They might be cumbersome to read and important information could be overseen quickly. To address this issue, a DQ assessment (DQA) tool with a graphical user interface (GUI) was developed and provided as a web application. METHODS: The aim was to provide an easy-to-use interface for users without prior programming knowledge to carry out DQ checks and to present the results in a clearly structured way. This interface serves as a starting point for a more detailed investigation of possible DQ irregularities. A user-centered development process ensured the practical feasibility of the interactive GUI. The interface was implemented in the R programming language and aligned to Kahn et al.'s DQ categories conformance, completeness and plausibility. RESULTS: With DQAgui, an R package with a web-app frontend for DQ assessment was developed. The GUI allows users to perform DQ analyses of tabular data sets and to systematically evaluate the results. During the development of the GUI, additional features were implemented, such as analyzing a subset of the data by defining time periods and restricting the analyses to certain data elements. CONCLUSIONS: As part of the MIRACUM project, DQAgui is now being used at ten German university hospitals for DQ assessment and to provide a central overview of the availability of important data elements in a datamap over 2 years. Future development efforts should focus on design optimization and include a usability evaluation.

Evaluating the usability of a national health information system with heuristic method.

BACKGROUND: Hospital Statistics and Information System is one of the most important health information systems in Iran used in all hospitals in this country. Usability problems can reduce the speed and precision of users when interacting with this system. This study aimed to identify the usability problems of a national health system called "AVAB". MATERIALS AND METHODS: This descriptive cross-sectional study was conducted in 2020, and three experts evaluated the usability of this system independently by the heuristic evaluation method. Nielsen's usability principles were used to identify usability problems and to classify their severity. RESULTS: A total of 86 unique problems were identified. The highest number of problems were related to the two principles of "help and documentation" and "match between system and the real world" with 23 and 11 usability problems, respectively. The lowest number of problems were related to the two principles of "visibility of system status" and "help users recognize, diagnose, and recover from errors," each with three problems. 58.1% of the identified problems were in the group of major and catastrophic problems. CONCLUSIONS: With the help of heuristic evaluation method, a significant number of usability problems of Hospital Statistics and Information System were identified. Most of the identified problems were major and catastrophic, and it is necessary to solve these problems by the designers and developers of this system.

Usability Evaluation of a Modern Multilingual MeSH Browser.

Medical Subject Headings (MeSH) is one of the most important vocabularies for information retrieval in medical research. It enables fast and reliable retrieval of research on PubMed/MEDLINE, the world's largest body of medical literature. The original English version of the thesaurus can be accessed via a MeSH Browser developed by the NLM. Recently, a multilingual MeSH Browser was proposed to enable usage across languages. To improve upon the original system, a new user interface (UI) was developed using contemporary web design frameworks in combination with principles from cognitive science. It aims to simplify access for medical professionals and increase overall usability. Evaluating such design improvements continually is necessary to quantify the possible positive impact for online systems in medical research. This study therefore directly compares the resulting system to the NLM Browser, using an established online questionnaire. Results show significant improvements in content and navigation as well as overall user satisfaction, while offering feedback for future improvements. This underlines the benefits of employing contemporary web design in terms of usability and user satisfaction.

Medical data formatting to improve physician interpretation speed in the Military Healthcare System.

Objective: The purpose of this project was to improve ease and speed of physician comprehension when interpreting daily laboratory data for patients admitted within the Military Healthcare System (MHS). Materials and Methods: A JavaScript program was created to convert the laboratory data obtained via the outpatient electronic medical record (EMR) into a "fishbone diagram" format that is familiar to most physicians. Using a balanced crossover design, 35 internal medicine trainees and staff at Naval Medical Center Portsmouth were asked to complete timed comprehension tests for laboratory data sets formatted in the outpatient EMR's format and in fishbone diagram format. The number of responses per second and error rate per response were measured for each format. Participants were asked to rate relative ease of use for each format and indicate which format they preferred. Results: Comprehension speed increased 37% (6.28 seconds per interpretation) with the fishbone diagram format with no observed increase in errors. Using a Likert scale of 1-5 (1 being hard, 5 easy), participants indicated the new format was easier to use (4.14 for fishbone vs 2.14 for table) with 89% expressing preference for the new format. Discussion: The publically available web application that converts tabular lab data to fishbone diagram format is currently used 10 000-12 000 times per month across the MHS, delivering significant benefit to the enterprise in terms of time saved and improved physician experience. Conclusions: This study supports the use of fishbone diagram formatting for laboratory data for inpatients within the MHS.