Electronic Health Records' Support for Primary Care Physicians' Situation Awareness: A Metanarrative Review.

OBJECTIVE: Situation awareness (SA) refers to people's perception and understanding of their dynamic environment. In primary care, reduced SA among physicians increases errors in clinical decision-making and, correspondingly, patients' risk of experiencing adverse outcomes. Our objective was to understand the extent to which electronic health records (EHRs) support primary care physicians (PCPs)' SA during clinical decision-making. METHOD: We conducted a metanarrative review of papers in selected academic databases, including CINAHL and MEDLINE. Eligible studies included original peer-reviewed research published between January 2012 and August 2020 on PCP-EHR interactions. We iteratively queried, screened, and summarized literature focused on EHRs supporting PCPs' clinical decision-making and care management for adults. Then, we mapped findings to an established SA framework to classify external factors (individual, task, and system) affecting PCPs' levels of SA (1-Perception, 2-Comprehension, and 3-Projection) and identified SA barriers. RESULTS: From 1504 articles identified, we included and synthesized 19 studies. Study designs were largely noninterventional. Studies described EHR workflow misalignments, usability issues, and communication challenges. EHR information, including lab results and care plans, was characterized as incomplete, untimely, or irrelevant. Unmet information needs made it difficult for PCPs to obtain even basic SA, Level 1 SA. Prevalent barriers to PCPs developing SA with EHRs were errant mental models, attentional tunneling, and data overload. CONCLUSION: Based on our review, EHRs do not support the development of higher levels of SA among PCPs. Review findings suggest SA-oriented design processes for health information technology could improve PCPs' SA, satisfaction, and decision-making.

Electronic Co-design (ECO-design) Workshop for Increasing Clinician Participation in the Design of Health Services Interventions: Participatory Design Approach.

BACKGROUND: Participation from clinician stakeholders can improve the design and implementation of health care interventions. Participatory design methods, especially co-design methods, comprise stakeholder-led design activities that are time-consuming. Competing work demands and increasing workloads make clinicians' commitments to typical participatory methods even harder. The COVID-19 pandemic further exacerbated barriers to clinician participation in such interventions. OBJECTIVE: The aim of this study was to explore a web-based participatory design approach to conduct economical, electronic co-design (ECO-design) workshops with primary care clinicians. METHODS: We adapted traditional in-person co-design workshops to web-based delivery and adapted co-design workshop series to fit within a single 1-hour session. We applied the ECO-design workshop approach to codevelop feedback interventions regarding abnormal test result follow-up in primary care. We conducted ECO-design workshops with primary care clinicians at a medical center in Southern Texas, using videoconferencing software. Each workshop focused on one of three types of feedback interventions: conversation guide, email template, and dashboard prototype. We paired electronic materials and software features to facilitate participant interactions, prototyping, and data collection. The workshop protocol included four main activities: problem identification, solution generation, prototyping, and debriefing. Two facilitators were assigned to each workshop and one researcher resolved technical problems. After the workshops, our research team met to debrief and evaluate workshops. RESULTS: A total of 28 primary care clinicians participated in our ECO-design workshops. We completed 4 parallel workshops, each with 5-10 participants. We conducted traditional analyses and generated a clinician persona (ie, representative description) and user interface prototypes. We also formulated recommendations for future ECO-design workshop recruitment, technology, facilitation, and data collection. Overall, our adapted workshops successfully enabled primary care clinicians to participate without increasing their workload, even during a pandemic. CONCLUSIONS: ECO-design workshops are viable, economical alternatives to traditional approaches. This approach fills a need for efficient methods to involve busy clinicians in the design of health care interventions.

Teaching pursed-lip breathing through music: MELodica Orchestra for DYspnea (MELODY) trial rationale and protocol.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) commonly experience dyspnea, which may limit activities of daily living. Pursed-lip breathing improves dyspnea for COPD patients; however, access to pursed-lip breathing training is limited. METHODS: The proposed MELodica Orchestra for DYspnea (MELODY) study will be a single-site pilot study to assess the safety, feasibility, and efficacy of a music-based approach to teach pursed-lip breathing. Patients with COPD and moderate-severe dyspnea are randomized to intervention, education-control, or usual care control groups. Intervention patients meet twice weekly for eight weeks for melodica instruction, group music-making, and COPD education. Safety, feasibility, and efficacy is assessed qualitatively and quantitatively. RESULTS: This manuscript describes the rationale and methods of the MELODY pilot project. CONCLUSIONS: If pilot data demonstrate efficacy, then a multi-site randomized control trial will be conducted to evaluate program effectiveness and implementation.

Clinician Perspectives on Unmet Needs for Mobile Technology Among Hospitalists: Workflow Analysis Based on Semistructured Interviews.

BACKGROUND: The hospitalist workday is cognitively demanding and dominated by activities away from patients' bedsides. Although mobile technologies are offered as solutions, clinicians report lower expectations of mobile technology after actual use. OBJECTIVE: The purpose of this study is to better understand opportunities for integrating mobile technology and apps into hospitalists' workflows. We aim to identify difficult tasks and contextual factors that introduce inefficiencies and characterize hospitalists' perspectives on mobile technology and apps. METHODS: We conducted a workflow analysis based on semistructured interviews. At a Midwestern US medical center, we recruited physicians and nurse practitioners from hospitalist and inpatient teaching teams and internal medicine residents. Interviews focused on tasks perceived as frequent, redundant, and difficult. Additionally, participants were asked to describe opportunities for mobile technology interventions. We analyzed contributing factors, impacted workflows, and mobile app ideas. RESULTS: Over 3 months, we interviewed 12 hospitalists. Participants collectively identified chart reviews, orders, and documentation as the most frequent, redundant, and difficult tasks. Based on those tasks, the intake, discharge, and rounding workflows were characterized as difficult and inefficient. The difficulty was associated with a lack of access to electronic health records at the bedside. Contributing factors for inefficiencies were poor usability and inconsistent availability of health information technology combined with organizational policies. Participants thought mobile apps designed to improve team communications would be most beneficial. Based on our analysis, mobile apps focused on data entry and presentation supporting specific tasks should also be prioritized. CONCLUSIONS: Based on our results, there are prioritized opportunities for mobile technology to decrease difficulty and increase the efficiency of hospitalists' workflows. Mobile technology and task-specific mobile apps with enhanced usability could decrease overreliance on hospitalists' memory and fragmentation of clinical tasks across locations. This study informs the design and implementation processes of future health information technologies to improve continuity in hospital-based medicine.

Building cohesion in distributed telemedicine teams: findings from the Department of Veterans Affairs National Telestroke Program.

BACKGROUND: As telemedicine adoption increases, so does the importance of building cohesion among physicians in telemedicine teams. For example, in acute telestroke services, stroke specialists provide rapid remote stroke assessment and treatment to patients at hospitals without stroke specialty care. In the National Telestroke Program (NTSP) of the U.S. Department of Veterans Affairs, a virtual (distributed) hub of stroke specialists throughout the country provides 24/7 consultations nationwide. We examined how these specialists adapted to distributed teamwork, and we identified cohesion-related factors in program development and support. METHODS: We studied the virtual hub of stroke specialists employed by the NTSP. Semi-structured, confidential interviews with stroke specialists in the virtual hub were recorded and transcribed. We explored the extent to which these specialists had developed a sense of shared identity and team cohesion, and we identified factors in this development. Using a qualitative approach with constant comparison methods, two researchers coded each interview transcript independently using a shared codebook. We used matrix displays to identify themes, with special attention to team cohesion, communication, trust, and satisfaction. RESULTS: Of 13 specialists with at least 8 months of NTSP practice, 12 completed interviews; 7 had previously practiced in telestroke programs in other healthcare systems. Interviewees reported high levels of trust and team cohesion, sometimes even more with their virtual colleagues than with co-located colleagues. Factors facilitating perceived team cohesion included a weekly case conference call, a sense of transparency in discussing challenges, engagement in NTSP development tasks, and support from the NTSP leadership. Although lack of in-person contact was associated with lower cohesion, annual in-person NTSP meetings helped mitigate this issue. Despite technical challenges in establishing a new telehealth system within existing national infrastructure, providers reported high levels of satisfaction with the NTSP. CONCLUSION: A virtual telestroke hub can provide a sense of team cohesion among stroke specialists at a level comparable with a standard co-located practice. Engaging in transparent discussion of challenging cases, reviewing new clinical evidence, and contributing to program improvements may promote cohesion in distributed telemedicine teams.

Utilizing a user-centered approach to develop and assess pharmacogenomic clinical decision support for thiopurine methyltransferase.

BACKGROUND: A pharmacogenomic clinical decision support tool (PGx-CDS) for thiopurine medications can help physicians incorporate pharmacogenomic results into prescribing decisions by providing up-to-date, real-time decision support. However, the PGx-CDS user interface may introduce errors and promote alert fatigue. The objective of this study was to develop and evaluate a prototype of a PGx-CDS user interface for thiopurine medications with user-centered design methods. METHODS: This study had two phases: In phase I, we conducted qualitative interviews to assess providers' information needs. Interview transcripts were analyzed through a combination of inductive and deductive qualitative analysis to develop design requirements for a PGx-CDS user interface. Using these requirements, we developed a user interface prototype and evaluated its usability (phase II). RESULTS: In total, 14 providers participated: 10 were interviewed in phase I, and seven providers completed usability testing in phase II (3 providers participated in both phases). Most (90%) participants were interested in PGx-CDS systems to help improve medication efficacy and patient safety. Interviews yielded 11 themes sorted into two main categories: 1) health care providers' views on PGx-CDS and 2) important design features for PGx-CDS. We organized these findings into guidance for PGx-CDS content and display. Usability testing of the PGx-CDS prototype showed high provider satisfaction. CONCLUSION: This is one of the first studies to utilize a user-centered design approach to develop and assess a PGx-CDS interface prototype for Thiopurine Methyltransferase (TPMT). This study provides guidance for the development of a PGx-CDS, and particularly for biomarkers such as TPMT.

A cognitive systems engineering design approach to improve the usability of electronic order forms for medical consultation.

BACKGROUND: During medical referrals, communication barriers between referring and consulting outpatient clinics delay patients' access to health care. One notable opportunity for reducing these barriers is improved usefulness and usability of electronic medical consultation order forms. The cognitive systems engineering (CSE) design approach focuses on supporting humans in managing cognitive complexity in sociotechnical systems. Cognitive complexity includes communication, decision-making, problem solving, and planning. OBJECTIVE: The objective of this research was to implement a CSE design approach to develop a template that supports the cognitive needs of referring clinicians and improves referral communication. METHODS: We conducted interviews and observations with primary care providers and specialists at two major tertiary, urban medical facilities. Using qualitative analysis, we identified cognitive requirements and design guidelines. Next, we designed user interface (UI) prototypes and compared their usability with that of a currently implemented UI at a major Midwestern medical facility. RESULTS: Physicians' cognitive challenges were summarized in four cognitive requirements and 13 design guidelines. As a result, two UI prototypes were developed to support order template search and completion. To compare UIs, 30 clinicians (referrers) participated in a consultation ordering simulation complemented with the think-aloud elicitation method. Oral comments about the UIs were coded for both content and valence (i.e., positive, neutral, or negative). Across 619 comments, the odds ratio for the UI prototype to elicit higher-valenced comments than the implemented UI was 13.5 (95% CI = [9.2, 19.8]), p < .001. CONCLUSION: This study reinforced the significance of applying a CSE design approach to inform the design of health information technology. In addition, knowledge elicitation methods enabled identification of physicians' cognitive requirements and challenges when completing electronic medical consultation orders. The resultant knowledge was used to derive design guidelines and UI prototypes that were more useful and usable for referring physicians. Our results support the implementation of a CSE design approach for electronic medical consultation orders.

Comparative usability evaluation of consultation order templates in a simulated primary care environment.

Communication breakdowns in the referral process negatively impact clinical workflow and patient safety. There is a lack of evidence demonstrating the impact of published design recommendations addressing contributing issues with consultation order templates. This study translated the recommendations into a computer-based prototype and conducted a comparative usability evaluation. With a scenario-based simulation, 30 clinicians (referrers) participated in a within-group, counterbalanced experiment comparing the prototype with their present electronic order entry system. The prototype significantly increased satisfaction (Cohen's d = 1.80, 95% CI [1.19, 2.41], p < .001), and required significantly less mental effort (d = 0.67 [0.14, 1.20], p < .001). Regarding efficiency, the prototype required significantly fewer mouse clicks (mean difference = 29 clicks, p < .001). Although overall task time did not differ significantly (d = -0.05 [-0.56, 0.47]), the prototype significantly quickened identification of the appropriate specialty clinic (mean difference = 12 s, d = 0.98 [0.43, 1.52], p < .001). The experimental evidence demonstrated that clinician-centered interfaces significantly improved system usability during ordering of consultations.

Usability Assessment of Secure Messaging for Clinical Document Sharing between Health Care Providers and Patients.

BACKGROUND: Web-based patient portals feature secure messaging systems that enable health care providers and patients to communicate information. However, little is known about the usability of these systems for clinical document sharing. OBJECTIVE: This article evaluates the usability of a secure messaging system for providers and patients in terms of its ability to support sharing of electronic clinical documents. METHODS: We conducted usability testing with providers and patients in a human-computer interaction laboratory at a Midwestern U.S. hospital. Providers sent a medication list document to a fictitious patient via secure messaging. Separately, patients retrieved the clinical document from a secure message and returned it to a fictitious provider. We collected use errors, task completion, task time, and satisfaction. RESULTS: Twenty-nine individuals participated: 19 providers (6 physicians, 6 registered nurses, and 7 pharmacists) and 10 patients. Among providers, 11 (58%) attached and sent the clinical document via secure messaging without requiring assistance, in a median (range) of 4.5 (1.8-12.7) minutes. No patients completed tasks without moderator assistance. Patients accessed the secure messaging system within 3.6 (1.2-15.0) minutes; retrieved the clinical document within 0.8 (0.5-5.7) minutes; and sent the attached clinical document in 6.3 (1.5-18.1) minutes. Although median satisfaction ratings were high, with 5.8 for providers and 6.0 for patients (scale, 0-7), we identified 36 different use errors. Physicians and pharmacists requested additional features to support care coordination via health information technology, while nurses requested features to support efficiency for their tasks. CONCLUSION: This study examined the usability of clinical document sharing, a key feature of many secure messaging systems. Our results highlight similarities and differences between provider and patient end-user groups, which can inform secure messaging design to improve learnability and efficiency. The observations suggest recommendations for improving the technical aspects of secure messaging for clinical document sharing.

Usability evaluation of a medication reconciliation tool: Embedding safety probes to assess users' detection of medication discrepancies.

OBJECTIVE: An electronic medication reconciliation tool was previously developed by another research team to aid provider-patient communication for medication reconciliation. To evaluate the usability of this tool, we integrated artificial safety probes into standard usability methods. The objective of this article is to describe this method of using safety probes, which enabled us to evaluate how well the tool supports users' detection of medication discrepancies. MATERIALS AND METHODS: We completed a mixed-method usability evaluation in a simulated setting with 30 participants: 20 healthcare professionals (HCPs) and 10 patients. We used factual scenarios but embedded three artificial safety probes: (1) a missing medication (i.e., omission); (2) an extraneous medication (i.e., commission); and (3) an inaccurate dose (i.e., dose discrepancy). We measured users' detection of each probe to estimate the probability that a HCP or patient would detect these discrepancies. Additionally, we recorded participants' detection of naturally occurring discrepancies. RESULTS: Each safety probe was detected by ≤50% of HCPs. Patients' detection rates were generally higher. Estimates indicate that a HCP and patient, together, would detect 44.8% of these medication discrepancies. Additionally, HCPs and patients detected 25 and 45 naturally-occurring discrepancies, respectively. DISCUSSION: Overall, detection of medication discrepancies was low. Findings indicate that more advanced interface designs are warranted. Future research is needed on how technologies can be designed to better aid HCPs' and patients' detection of medication discrepancies. CONCLUSION: This is one of the first studies to evaluate the usability of a collaborative medication reconciliation tool and assess HCPs' and patients' detection of medication discrepancies. Results demonstrate that embedded safety probes can enhance standard usability methods by measuring additional, clinically-focused usability outcomes. The novel safety probes we used may serve as an initial, standard set for future medication reconciliation research. More prevalent use of safety probes could strengthen usability research for a variety of health information technologies.

Systematic Heuristic Evaluation of Computerized Consultation Order Templates: Clinicians' and Human Factors Engineers' Perspectives.

We assessed the usability of consultation order templates and identified problems to prioritize in design efforts for improving referral communication. With a sample of 26 consultation order templates, three evaluators performed a usability heuristic evaluation. The evaluation used 14 domain-independent heuristics and the following three supplemental references: 1 new domain-specific heuristic, 6 usability goals, and coded clinicians' statements regarding ease of use for 10 sampled templates. Evaluators found 201 violations, a mean of 7.7 violations per template. Minor violations outnumbered major violations almost twofold, 115 (57%) to 62 (31%). Approximately 68% of violations were linked to 5 heuristics: aesthetic and minimalist design (17%), error prevention (16%), consistency and standards (14%), recognition rather than recall (11%), and meet referrers' information needs (10%). Severe violations were attributed mostly to meet referrers' information needs and recognition rather than recall. Recorded violations yielded potential negative consequences for efficiency, effectiveness, safety, learnability, and utility. Evaluators and clinicians demonstrated 80% agreement in usability assessment. Based on frequency and severity of usability heuristic violations, the consultation order templates reviewed may impede clinical efficiency and risk patient safety. Results support the following design considerations: communicate consultants' requirements, facilitate information seeking, and support communication. While the most frequent heuristic violations involved interaction design and presentation, the most severe violations lacked information desired by referring clinicians. Violations related to templates' inability to support referring clinicians' information needs had the greatest potential negative impact on efficiency and safety usability goals. Heuristics should be prioritized in future design efforts.

The Uncanny Valley Does Not Interfere with Level 1 Visual Perspective Taking.

When a computer-animated human character looks eerily realistic, viewers report a loss of empathy; they have difficulty taking the character's perspective. To explain this perspective-taking impairment, known as the uncanny valley, a novel theory is proposed: The more human or less eerie a character looks, the more it interferes with level 1 visual perspective taking when the character's perspective differs from that of the human observer (e.g., because the character competitively activates shared circuits in the observer's brain). The proposed theory is evaluated in three experiments involving a dot-counting task in which participants either assumed or ignored the perspective of characters varying in their human photorealism and eeriness. Although response times and error rates were lower when the number of dots faced by the observer and character were the same (congruent condition) than when they were different (incongruent condition), no consistent pattern emerged between the human photorealism or eeriness of the characters and participants' response times and error rates. Thus, the proposed theory is unsupported for level 1 visual perspective taking. As the effects of the uncanny valley on empathy have not previously been investigated systematically, these results provide evidence to eliminate one possible explanation.