Electronic Medical Records: the search for clinical meaning
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Dr Dave Pao presents the background to EMR interface UX design and how we can improve clinical reasoning through visualisation. At UXD Amsterdam 2019.
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Electronic Medical Records: the search for clinical meaning
- 1. Dr Dave Pao Electronic Medical Records: the search for clinical meaning UXD Amsterdam 2019
- 3. Imison, C. Delivering the benefits of digital health care. The Nuffield Trust, 2017 The Electronic Medical Record (EMR) DATA COLLECTED [OR VERIFIED] AT THE POINT OF CLINICAL CARE dpao@nhs.net
- 4. Electronic Medical Record (EMR) Lisa Strausfeld Pangaro Personal Health Record (PHR) ‘EXPLANATION for the uninitiated...’ ‘EXPLORATION for the experts.’ dpao@nhs.net
- 6. … and procedures We examine the patient, we may take swabs, do a procedure, use a microscope, do urine and blood point of care tests etc. etc. – more data input dpao@nhs.net
- 7. … we need the previous history We need data coming back at us from previous visits, quickly and accurately. This supports our clinical reasoning. dpao@nhs.net
- 8. Clinical reasoning “The use of a patient's history, physical signs, symptoms, laboratory data, and radiological images to arrive at a diagnosis and formulate a plan of treatment.” dpao@nhs.net
- 9. dpao@nhs.net
- 10. Elwyn, G, 2014 Patientgate - digital recordings change everything. British Medical Journal, vol. 348. p. 2078, ‘We have medical records, but they are like the shadows on the wall of a cave, punctuated by codes and jargon.’ dpao@nhs.net
- 11. We need to re-imagine ubiquitous EMR layout and move beyond dropdowns, tabs and text panels… dpao@nhs.net
- 15. Commercial Regulatory EMR Development UX / Vis Research Where is medicine? dpao@nhs.net
- 16. Current UX needs deeper medical collaboration with research that starts BEFORE the ubiquitous EMR layout
- 17. Zhang, Jiajie Journal of Biomedical Informatics 2011; 44: 1056–1067
- 18. Zhang, Jiajie Journal of Biomedical Informatics 2011; 44: 1056–1067dpao@nhs.net
- 19. Zhang, Jiajie Journal of Biomedical Informatics 2011; 44: 1056–1067 AMIA / TURF Usability Principles dpao@nhs.net
- 20. Zhang, Jiajie Journal of Biomedical Informatics 2011; 44: 1056–1067 Violations of usability principles AHLTA EHR The first six principles (consistency, visibility, match, minimalist, memory, and feedback) are all about the representation properties of the user interfaces, and they are considered as one type of representation analysis.dpao@nhs.net
- 21. Tracks computer-based activity, speech interaction, visual attention and body movements, and automatically synchronize and segment these data.
- 22. EMR Development UX / Vis Research Medicine dpao@nhs.net
- 23. ‘...a graphical summary should encourage doctors and nurses to reshape, perhaps re-invent, the medical record before computer programmers cast institutional convenience into silicon’ [1997] dpao@nhs.net
- 24. dpao@nhs.net
- 25. Think fast, think slow Kahneman, D. 2011dpao@nhs.net
- 28. Powsner, SM, et al. Graphical summary of patient status Lancet, vol. 344(8919), pp. 386-9, 1994
- 29. Visualisation using Metaphor Horn, W, 2001
- 30. Lifelines, 1998 Plaisant & Shneiderman
- 32. Boer, L et al. Provotypes for participatory innovation. Proceedings of the Designing Interactive Systems Conference. Newcastle, UK, 11 – 15 June, 2012 Belief: visualisation supports clinical reasoning Method: a provotype dashboard explores usability principles for clinical reasoning APPROACH dpao@nhs.net
- 33. Boer, L et al. Provotypes for participatory innovation. Proceedings of the Designing Interactive Systems Conference. Newcastle, UK, 11 – 15 June, 2012 A provocative prototype provokes and engages people to imagine possible futures PROVOTYPE dpao@nhs.net
- 35. Regarding the EPR that you use, how much do you agree or disagree with these statements? [7-point Likert]: 1. It is easy to search for things 2. There is good use of graphics 3. Accuracy of records improves with more visits 4. The screen layout reflects clinical real life 5. It is easy to get an overview of the patient’s history 6. I am satisfied with how the EPR supports my job 7. What I write can get lost in the system* 8. I wish I didn’t have to double-click so much* 9. It helps my memory work more effectively 10.There are redundant words / boxes on the screen* 11.I enjoy using it 12.It is easy to make sense of laboratory results 13.It is easy to set alerts about important issues 14.Information is in easily understood patterns *denotes negative statement dpao@nhs.net DRAFT QUESTIONNAIRE
- 37. 1. Competence 2. Relationship with patient 3. Clinician you want to be 4. Frustrate 5. Like 6. Could it be better QUALITATIVE BOXES dpao@nhs.net
- 38. “Our EPR is unsafe as it is difficult or almost impossible to track what has happened to a patient in the past We have had several serious incidents.” 2500 words dpao@nhs.net
- 39. 11/18 “...does not allow for 1000s of possible bits of information that a patient may offer that don’t quite fit into tick boxes.” dpao@nhs.net
- 40. “More templates, more get- arounds, more headaches and frustration!” dpao@nhs.net
- 41. 17/18 “... the user interface needs to be on one page with the data items in a logical order that mirrors the clinical consultation with minimal clicks/pages to go through.” dpao@nhs.net
- 42. 13/18 “It is not intuitive and wastes clinical time.” dpao@nhs.net
- 43. 16/18 “I use paper recording during consultations then enter EMR after patient out of room.” dpao@nhs.net
- 44. Performance Frustration, sense of incompetence, time inefficiency, poor history overview, poor clinical relevance, repeated questioning, difficulty with complex patients, difficulty with patients with multiple previous visits, impaired flow of consultation, difficulty maintaining eye contact / rapport and some even using paper before transcribing into EMR, not ‘losing’ records, benefit of remote site accessibility Interface: Unintuitive information accessibility, low data density, nonsensical data location, multiple windows, too much double- clicking, getting lost, difficulty understanding results, confusing, difficulty accessing: vaccination history, treatment history, allergies, test results and critical alert, legibility Qualitative dpao@nhs.net
- 45. 1. Competence 2. Relationship with patient 3. Clinician you want to be 4. Frustrate 5. Like 6. Could it be better Qualitative dpao@nhs.net
- 46. Functionality Getting lost: too many windows Flow: reflect clinical reality, our landscape Time-dependent data: timeline overview, semantic zoom Complex Data: chunking, glyphs, screen ‘real estate’ Template: data input Time-independent data: data salience, at a glance 1. Competence 2. Relationship with patient 3. Clinician you want to be 4. Frustrate 5. Like 6. Could it be better Qualitative dpao@nhs.net
- 47. dpao@nhs.net
- 48. dpao@nhs.net
- 50. Test drives • 117 clinical users, all levels • Repeat survey • 12 hours of workshop audio • Refinement of CRUX principles dpao@nhs.net
- 51. Test drives • 117 clinical users, all levels • Repeat survey • 12 hours of workshop audio • Refinement of CRUX principles dpao@nhs.net
- 53. 500 words “Really helpful and efficient to have windows opening, rather than hopping in and out of screens (which slows down consultations). Loved it.” dpao@nhs.net
- 54. “Intuitive. In just a few coloured dots I can recognise what the clinical picture is.” dpao@nhs.net
- 55. “It would be user-friendly and enable us as clinicians to engage with the patient more rather than screw through every episode trying to find what has gone before.” dpao@nhs.net
- 56. “Really like the flexibility ‘just shoot’ learning style of use.” dpao@nhs.net
- 57. “Great way of presenting info, can we have it tomorrow please? ” dpao@nhs.net
- 58. Test drives • 117 clinical users, all levels • Repeat survey • 12 hours of workshop audio • Refinement of CRUX principles dpao@nhs.net
- 59. Performance: Desire to try in a real clinic, ‘want this now’, vast improvement, looks brilliant, highly intuitive, more satisfying, easier, safer, better engagement, more time efficient, less repeated questioning likely Interface: Good history overview, good use of colour, efficiency of single window, easy pattern recognition despite complexity, daunting at first but quick to learn, love use of glyphs, user-friendly, good information visualisation, good data density (not overcrowded), useful salient information dpao@nhs.net
- 60. ‘Regarding the clinical dashboard or EMR that you use, how much do you agree or disagree with these statements?’ (7-point Likert scale responses required) 1. It gives me a good overview of the patient history with minimal clicking 2. Salient social and clinical data is always visible at a high level 3. Laboratory results are laid out in intuitive patterns with drill-down capability 4. I do not have to jump in and out of different screens 5. Salient previous history pulls through so I do not have to ask the same questions repeatedly 6. Information becomes more streamlined each time the patient attends 7. It supports the flow of the consultation and patient eye contact 8. It helps my memory work effectively by offering pattern recognition 9. I can quickly learn to use this system by practice, rather than by instruction 10.I can easily navigate and explore a complex information landscape UX QUESTIONNAIRE for clinical reasoning dpao@nhs.net
- 62. dpao@nhs.net
- 64. dpao@nhs.net
- 65. dpao@nhs.net
- 67. Cross, N. Designerly ways of knowing Design Studies vol. 3(4), pp. 221-227, 1982 Design as 3rd Culture dpao@nhs.net
- 68. As an aesthetic principle, the machinic [interface] is associated with process rather than object, with dynamics rather than finality, with instability rather than permanence, with communication rather than representation, with action and with play. ‘Remove the Controls’ Essay by Andreas Broeckmann (1997 Machine Aesthetics dpao@nhs.net
- 69. Health UX principles tell us what, not how The consultation is an unfolding, unknown, uncertain landscape for everyone Institutionalised silicon - dropdowns, tabs and text panels Task alone is not enough, we need exploration - clinical reasoning, experiential knowledge Problem ‘worrying’ is OK; don’t hide problems Takeaways dpao@nhs.net
Editor's Notes
- Paul Pangaro
- The first six principles (consistency, visibility, match, minimalist, memory, and feedback) are all about the representation properties of the user interfaces, and they are considered as one type of representation analysis.
- This talk describes a design method that holds to this ideal whilst at the same time supporting the work of the ‘computer programmer’
- Once in, recall data? HISTORY. ARCHIVE. Demographics, clinical notes, letters to, letters from, from pt, scan reports, 100’s of result sheets Nuance, visuals, flicking – thickness tells all Tactile Delight
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- 17
- Competence: Getting lost, ‘It must feel for patients occasionally like we are meeting for the first time during follow-up appointments’ Relationship: FLOW, Eye contact, ‘EPR should aid and support clinical consultation and management process - the one HINDERS‘ Clinician: No overview, impossible to get story Frustrate: Complex Patients, Missing really important info, U18, SA, vax, STS, results Like: Nothing! Simple patients Better: I would like important info on the patient to stay with you as you move to new screen Pull-through historical data (e.g. Past Medical History, Drug history, allergies) Questions are asked repeatedly of patients, re-take History every time,, Amazon, other EPRs
- Competence: Getting lost, ‘It must feel for patients occasionally like we are meeting for the first time during follow-up appointments’ Relationship: FLOW, Eye contact, ‘EPR should aid and support clinical consultation and management process - the one HINDERS‘ Clinician: No overview, impossible to get story Frustrate: Complex Patients, Missing really important info, U18, SA, vax, STS, results Like: Nothing! Simple patients Better: I would like important info on the patient to stay with you as you move to new screen Pull-through historical data (e.g. Past Medical History, Drug history, allergies) Questions are asked repeatedly of patients, re-take History every time,, Amazon, other EPRs
- Microscopy by me – one page Test ordered grey – one page Test result neg green – another page Test result pos Hover result Double click certificate
- Microscopy by me – one page Test ordered grey – one page Test result neg green – another page Test result pos Hover result Double click certificate
- Microscopy by me – one page Test ordered grey – one page Test result neg green – another page Test result pos Hover result Double click certificate