Appl Clin Inform 2017; 08(02): 632-650
DOI: 10.4338/ACI-2016-12-RA-0209
Research Article
Schattauer GmbH

Developing Mobile Clinical Decision Support for Nursing Home Staff Assessment of Urinary Tract Infection using Goal-Directed Design

Wallace Jones
1  University of Colorado School of Medicine
Cynthia Drake
1  University of Colorado School of Medicine
David Mack
1  University of Colorado School of Medicine
Blaine Reeder
2  University of Colorado College of Nursing
Barbara Trautner
4  Section of Infectious Diseases, Departments of Medicine and Surgery, Baylor College of Medicine, Houston, Texas, USA
Heidi L Wald
1  University of Colorado School of Medicine
› Author Affiliations
Funding This work was supported by the Infectious Diseases Society of America Student Fellowship (WJ) and a grant from the COPIC Foundation.
Further Information

Publication History

received: 07 January 2017

accepted: 02 April 2017

Publication Date:
21 December 2017 (online)


Background: Unique characteristics of nursing homes (NHs) contribute to high rates of inappropriate antibiotic use for asymptomatic bacteriuria (ASB), a benign condition. A mobile clinical decision support system (CDSS) may support NH staff in differentiating urinary tract infections (UTI) from ASB and reducing antibiotic days.

Objectives: We used Goal-Directed Design to: 1) Characterize information needs for UTI identification and management in NHs; 2) Develop UTI Decide, a mobile CDSS prototype informed by personas and scenarios of use constructed from Aim 1 findings; 3) Evaluate the UTI Decide prototype with NH staff.

Methods: Focus groups were conducted with providers and nurses in NHs in Denver, Colorado (n = 24). Qualitative descriptive analysis was applied to focus group transcripts to identify information needs and themes related to mobile clinical decision support for UTI identification and management. Personas representing typical end users were developed; typical clinical context scenarios were constructed using information needs as goals. Usability testing was performed using cognitive walk-throughs and a think-aloud protocol.

Results: Four information needs were identified including guidance regarding resident assessment; communication with providers; care planning; and urine culture interpretation. Design of a web-based application incorporating a published decision support algorithm for evidence-based UTI diagnoses proceeded with a focus on nursing information needs during resident assessment and communication with providers. Certified nursing assistant (CNA) and registered nurse (RN) personas were constructed in 4 context scenarios with associated key path scenarios. After field testing, a high fidelity prototype of UTI Decide was completed and evaluated by potential end users. Design recommendations and content recommendations were elicited.

Conclusions: Goal-Directed Design informed the development of a mobile CDSS supporting participant-identified information needs for UTI assessment and communication in NHs. Future work will include iterative deployment and evaluation of UTI Decide in NHs to decrease inappropriate use of antibiotics for suspected UTI.

Citation: Jones W, Drake C, Mack D, Reeder B, Trautner B, Wald HL. Developing mobile clinical decision support for nursing home staff assessment of urinary tract infection using goal-directed design.Appl Clin Inform 2017; 8: 632–650

Clinical Relevance Statement

This study indicates that healthcare providers in the NH context are eager to be engaged in the design, development, and evaluation of information systems that support their work and decision making. Furthermore, results suggest that eCDSS could be successfully adopted in this context and integrated into the existing UTI diagnostic and management workflow in NHs.

Human Subjects Protections

The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects, and was reviewed by the Colorado Multiple Institutional Review Board.