Toward Designing Information Display to Support Critical Care

Summary

Objectives Electronic health information overload makes it difficult for providers to quickly find and interpret information to support care decisions. The purpose of this study was to better understand how clinicians use information in critical care to support the design of improved presentation of electronic health information.

Methods We conducted a contextual analysis and visioning project. We used an eye-tracker to record 20 clinicians’ information use activities in critical care settings. We played video recordings back to clinicians in retrospective cued interviews and queried: 1) context and goals of information use, 2) impacts of current display design on use, and 3) processes related to information use. We analyzed interview transcripts using grounded theory-based content analysis techniques and identified emerging themes. From these, we conducted a visioning activity with a team of subject matter experts and identified key areas for focus of design and research for future display designs.

Results Analyses revealed four unique critical care information use activities including new patient assessment, known patient status review, specific directed information seeking, and review and prioritization of multiple patients. Emerging themes were primarily related to a need for better representation of dynamic data such as vital signs and laboratory results, usability issues associated with reducing cognitive load and supporting efficient interaction, and processes for managing information. Visions for the future included designs that: 1) provide rapid access to new information, 2) organize by systems or problems as well as by current versus historical patient data, and 3) apply intelligence toward detecting and representing change and urgency.

Conclusions The results from this study can be used to guide the design of future acute care electronic health information display. Additional research and collaboration is needed to refine and implement intelligent graphical user interfaces to improve clinical information organization and prioritization to support care decisions.

Citation: Wright M, Dunbar S, Macpherson B, Moretti EW, Del Fiol G, Bolte J, Taekman JM, Segall, N. Toward designing information display to support critical care: A qualitative contextual evaluation and visioning effort.

Keywords

Electronic health records and systems - clinical decision support - monitoring and surveillance - clinical documentation and communications - intensive and critical care - human-computer interaction - interfaces and usability - safety - qualitative

 

Conflict of Interest

None declared.

• References

• 1 Newman-Toker D, Pronovost P. Diagnostic Errors--The Next Frontier for Patient Safety. JAMA: The Journal of the American Medical Association 2009; 301 (10) 1060-1062.
• 2 Leape LL, Berwick D, Bates D. Counting deaths due to medical errors. JAMA 2002; 288 (19) 2405.
• 3 Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL, Pizov R, Cotev S. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med 1995; 23 (02) 294-300.
• 4 Bracco D, Favre J, Bissonnette B, Wasserfallen J, Revelly J, Ravussin P, Chiolero R. Human errors in a multidisciplinary intensive care unit: a 1-year prospective study. Intensive Care Medicine 2001; 27 (01) 137-145.
• 5 Forster A, Kyeremanteng K, Hooper J, Shojania K, Van Walraven C. The impact of adverse events in the intensive care unit on hospital mortality and length of stay. BMC health services research 2008; 08 (01) 259.
• 6 Fackler J, Watts C, Grome A, Miller T, Crandall B, Pronovost P. Critical care physician cognitive task analysis: an exploratory study. Crit Care 2009; 13 (02) R33.
• 7 Ahmed AH, Giri J, Kashyap R, Singh B, Dong Y, Kilickaya O, Erwin PJ, Murad MH, Pickering BW. Outcome of adverse events and medical errors in the intensive care unit: a systematic review and meta-analysis. Am J Med Qual 2015; 30 (01) 23-30.
• 8 Meeks DW, Smith MW, Taylor L, Sittig DF, Scott JM, Singh H. An analysis of electronic health record-related patient safety concerns. J Am Med Inform Assoc 2014; 21 (06) 1053-1059.
• 9 Zhang J, Walji MF. TURF: Toward a unified framework of EHR usability. J Biomed Inform 2011; Dec; 44 (06) 1056-67.
• 10 Schumacher RM, Berkowitz L, Abramson P, Liebovitz D. Electronic Health Records: Physician’s Perspective on Usability. In: Proceedings of the Human Factors and Ergonomics Society 54th Annual Meeting. Santa Monica CA Human Factors and Ergonomics Society 2010
• 11 Gans D, Kralewski J, Hammons T, Dowd B. Medical groups’ adoption of electronic health records and information systems. Health Aff (Millwood) 2005; 24 (05) 1323-1333.
• 12 Armijo D, McDonnell C, Werner K. Electronic Health Record Usability: Interface Design Considerations. Rockville, MD 2009. Report No:.
• 13 Zahabi M, Kaber DB, Swangnetr M. Usability and Safety in Electronic Medical Records Interface Design: A Review of Recent Literature and Guideline Formulation. Hum Factors 2015; 57 (05) 805-834.
• 14 Zhou YY, Kanter MH, Wang JJ, Garrido T. Improved quality at Kaiser Permanente through e-mail between physicians and patients. Health Aff (Millwood) 2010; 29 (07) 1370-1375.
• 15 Russ A, Saleem J, Justice C, Hagg H, Woodbridge P, Doebbeling B. Healthcare Workers’ Perceptions of Information in the Electronic Health Record. Proceedings of the Human Factors and Ergonomics Society 53rd Annual Meeting. Santa Monica CA Human Factors and Ergonomics Society 2009
• 16 Weir CR, Nebeker JR. Critical issues in an electronic documentation system. AMIA Annual Symposium proceedings / AMIA Symposium AMIA Symposium 2007; 786-790.
• 17 Jaspers MW, Peute LW, Lauteslager A, Bakker PJ. Pre-post evaluation of physicians’ satisfaction with a redesigned electronic medical record system. Stud Health Technol Inform 2008; 136: 303-308.
• 18 Payne TH, Corley S, Cullen TA, Gandhi TK, Harrington L, Kuperman GJ, Mattison JE, McCallie DP, McDonald CJ, Tang PC, Tierney WM, Weaver C, Weir CR, Zaroukian MH. Report of the AMIA HER-2020 Task Force on the status and future direction of EHRs. J Am Med Inform Assoc 22 (05) 1102-1110.
• 19 Carayon P, Wetterneck TB, Alyousef B, Brown RL, Cartmill RS, McGuire K, Hoonakker PL, Slagle J, Van Roy KS, Walker JM, Weinger MB, Xie A, Wood KE. Impact of electronic health record technology on the work and workflow of physicians in the intensive care unit. International journal of medical informatics 2015; 84 (08) 578-594.
• 20 Pickering BW, Dong Y, Ahmed A, Giri J, Kilickaya O, Gupta A, Gajic O, Herasevich V. The implementation of clinician designed, human-centered electronic medical record viewer in the intensive care unit: a pilot step-wedge cluster randomized trial. International journal of medical informatics 2015; 84 (05) 299-307.
• 21 Zeng Q, Cimino JJ, Zou KH. Providing concept-oriented views for clinical data using a knowledge-based system: an evaluation. J Am Med Inform Assoc 2002; 09 (03) 294-305.
• 22 Gorges M, Kuck K, Koch SH, Agutter J, Westenskow DR. A far-view intensive care unit monitoring display enables faster triage. Dimensions of critical care nursing: DCCN 2011; 30 (04) 206-217.
• 23 Koch SH, Weir C, Westenskow D, Gondan M, Agutter J, Haar M, Liu D, Gorges M, Staggers N. Evaluation of the effect of information integration in displays for ICU nurses on situation awareness and task completion time: A prospective randomized controlled study. Int J Med Inform 2013; 82 (08) 665-675.
• 24 Faiola A, Srinivas P, Duke J. Supporting Clinical Cognition: A Human-Centered Approach to a Novel ICU Information Visualization Dashboard. AMIA Annu Symp Proc 2015; 2015: 560-569.
• 25 Holmes C, Brown M, Hilaire DS, Wright A. Healthcare provider attitudes towards the problem list in an electronic health record: a mixed-methods qualitative study. BMC medical informatics and decision making 2012; 12: 127.
• 26 Bauer DT, Guerlain S, Brown PJ. The design and evaluation of a graphical display for laboratory data. J Am Med Inform Assoc 2010; 17 (04) 416-424.
• 27 Evans RS, Larsen RA, Burke JP, Gardner RM, Meier FA, Jacobson JA, Conti MT, Jacobson JT, Hulse RK. Computer surveillance of hospital-acquired infections and antibiotic use. JAMA 1986; 256 (08) 1007-1011.
• 28 Herasevich V, Tsapenko M, Kojicic M, Ahmed A, Kashyap R, Venkata C, Shahjehan K, Thakur SJ, Pickering BW, Zhang J, Hubmayr RD, Gajic O. Limiting ventilator-induced lung injury through individual electronic medical record surveillance. Crit Care Med 2011; 39 (01) 34-39.
• 29 Kannampallil TG, Jones LK, Patel VL, Buchman TG, Franklin A. Comparing the information seeking strategies of residents, nurse practitioners, and physician assistants in critical care settings. J Am Med Inform Assoc 2014; 21 (e2): e249-e256.
• 30 Pickering BW, Gajic O, Ahmed A, Herasevich V, Keegan MT. Data Utilization for Medical Decision Making at the Time of Patient Admission to ICU*. Crit Care Med 2013; 41 (06) 1502-1510.
• 31 Saleem JJ, Plew WR, Speir RC, Herout J, Wilck NR, Ryan DM, Cullen TA, Scott JM, Beene MS, Phillips T. Understanding barriers and facilitators to the use of Clinical Information Systems for intensive care units and Anesthesia Record Keeping: A rapid ethnography. Int J Med Inform 2015; 84 (07) 500-511.
• 32 Yusof MM. A case study evaluation of a Critical Care Information System adoption using the socio-technical and fit approach. Int J Med Inform 2015; 84 (07) 486-499.
• 33 Endsley MR, Bolte B, Jones DG. Designing for Situation Awareness: An Approach to Human-Centered Design. London Taylor and Francis 2003
• 34 Holtzblatt K, Wendell J, Wood S. Rapid Contextual Design. San Francisco Elsevier, Inc 2005
• 35 Vicente KJ. Ecological interface design: progress and challenges. Hum Factors 2002; 44 (01) 62-78.
• 36 Vicente KJ, Rasmussen J. Ecological interface design: Theoretical foundations. IEEE Transactions on Systems, Man, and Cybernetics 1992; 22 (04) 589-606.
• 37 Burns CM, Hajdukiewicz JR. Ecological Interface Design. Boca Raton FL CRC Press 2004
• 38 Benard H, Killworth P, Kronenfeld D, Sailer L. The problem of informant accuracy: the validity of retrospective data. Annual Review of Anthropology 1984; 13: 495-517.
• 39 Klein D. When to ignore what people say. Ergonomics in Design. 2006 Winter.
• 40 Grinspan Z, Eldar Y, Gopher D, Gottlieb A, Lammfromm R, Mangat H, Peleg N, Pon S, Rozenberg I, Schiff N, Stark D, Yan P, Pratt H, Kosofsky B. Findings from an International Working Group. Applied Clinical Informatics 2016; 07 (02) 380-398.
• 41 Doberne JW, He Z, Mohan V, Gold JA, Marquard J, Chiang MF. Using High-Fidelity Simulation and Eye Tracking to Characterize EHR Workflow Patterns among Hospital Physicians. AMIA Annu Symp Proc 2015; 2015: 1881-1889.
• 42 Henneman E, Marquard J, Fisher D, Gawlinski A. Eye tracking: A novel approach for evaluating and improving the safety of healthcare processes. Simulation in Healthcare. In press.
• 43 Nelson SD, LaFleur J, Del Fiol G, Evans RS, Weir CR. Reading and Writing: Qualitative Analysis of Pharmacists’ Use of the EHR when Preparing for Team Rounds. AMIA Annu Symp Proc 2015; 2015: 943-952.
• 44 Seagull FJ, Xiao Y. Using eye-tracking video data to augment knowledge elicitation in cognitive task analysis. Proceedings of the Human Factors and Ergonomics Society 45th Annual Meeting. Santa Monica, CA Human Factors and Ergonomics Society 2001: 400-403.
• 45 Tien T, Pucher PH, Sodergren MH, Sriskandarajah K, Yang GZ, Darzi A. Eye tracking for skills assessment and training: a systematic review. J Surg Res 2014; 191 (01) 169-178.
• 46 Wright M, Dunbar S, Moretti E, Schroeder R, Taekman J, Segall N. editors. Eye-Tracking and Retrospective Verbal Protocol to Support Information Systems Design. Human Factors and Ergonomics Society Health Care Symposium. 2013 Baltimore, MD Human Factors and Ergonomics Society.
• 47 Duchowski A. Eye Tracking Methodology: Theory and Practice. 2nd ed.. London Springer 2007
• 48 Henneman E, Marquard J, Fisher D, Gawlinski A. Eye tracking: A novel approach for evaluating and improving the safety of healthcare processes. Simulation in Healthcare. Under review.
• 49 Poole A, Ball LJ. Eye-trackng in HCI and usability research. Encyclopedia of Human Computer Interaction 2006; 01: 211-219.
• 50 Kushniruk AW, Patel VL, Cimino JJ. Usability testing in medical informatics: cognitive approaches to evaluation of information systems and user interfaces. Proceedings : a conference of the American Medical Informatics Association / AMIA Annual Fall Symposium AMIA Fall Symposium 1997; Jan 01: 218-222.
• 51 Charmaz K. Constructing Grounded Theory. Thousand Oaks, CA Sage Publications Inc 2006
• 52 Beyer H, Holtzblatt K. Contextual Design: Defining Customer-Centered Systems. San Francisco CA Morgan Kaufmann 1977
• 53 Steinhauser KE. Qualitative Research Methods: An Overview. Clinical Research Training Program: Health Services Research: Duke University Medical Center. 2009
• 54 Mays N, Pope C. Qualitative research: Observational methods in health care settings. BMJ 1995; 15 Jul 311(6998): 182-4.
• 55 Zheng K, Padman R, Johnson MP, Diamond HS. An interface-driven analysis of user interactions with an electronic health records system. J Am Med Inform Assoc 2009; 16 (02) 228-237.
• 56 Molich R, Nielsen J. Improving a human-computer dialogue. Communications of the ACM 1990; 33: 338-48.
• 57 Bates DW, Kuperman GJ, Wang S, Gandhi T, Kittler A, Volk L, Spurr C, Khorasani R, Tanasijevic M, Middleton B. Ten commandments for effective clinical decision support: making the practice of evidencebased medicine a reality. J Am Med Inform Assoc 2003; 10 (06) 523-530.
• 58 Kennedy RR, Merry AF. The effect of a graphical interpretation of a statistic trend indicator (Trigg’s Tracking Variable) on the detection of simulated changes. Anaesthesia and intensive care 2011; 39 (05) 881-886.
• 59 Tappan JM, Daniels J, Slavin B, Lim J, Brant R, Ansermino JM. Visual cueing with context relevant information for reducing change blindness. J Clin Monit Comput 2009; 23 (04) 223-232.
• 60 Herasevich V, Kor DJ, Subramanian A, Pickering BW. Connecting the dots: rule-based decision support systems in the modern EMR era. Journal of clinical monitoring and computing 2013; 27 (04) 443-448.
• 61 Lynn LA, Curry JP. Patterns of unexpected in-hospital deaths: a root cause analysis. Patient safety in surgery 2011; 05 (01) 3

Publication History

Received: 15 March 2016

Accepted: 23 August 2016

Publication Date:
18 December 2017 (online)