Objective Develop and evaluate an interactive information visualization embedded within the electronic health record (EHR) by following human-centered design (HCD) processes and leveraging modern health information exchange standards. Materials and Methods We applied an HCD process to develop a Fast Healthcare Interoperability Resources (FHIR) application that displays a patient’s asthma history to clinicians in a pediatric emergency department. We performed a preimplementation comparative system evaluation to measure time on task, number of screens, information retrieval accuracy, cognitive load, user satisfaction, and perceived utility and usefulness. Application usage and system functionality were assessed using application logs and a postimplementation survey of end users. Results Usability testing of the Asthma Timeline Application demonstrated a statistically significant reduction in time on task (P < .001), number of screens (P < .001), and cognitive load (P < .001) for clinicians when compared to base EHR functionality. Postimplementation evaluation demonstrated reliable functionality and high user satisfaction. Discussion Following HCD processes to develop an application in the context of clinical operations/quality improvement is feasible. Our work also highlights the potential benefits and challenges associated with using internationally recognized data exchange standards as currently implemented. Conclusion Compared to standard EHR functionality, our visualization increased clinician efficiency when reviewing the charts of pediatric asthma patients. Application development efforts in an operational context should leverage existing health information exchange standards, such as FHIR, and evidence-based mixed methods approaches.
Background Helping parents quit smoking is a public health priority. However, parents are rarely, if ever, offered tobacco use treatment through pediatric settings. Clinical decision support (CDS) systems developed for the workflows of pediatric primary care may support consistent screening, treatment, and referral. Objectives This study aimed to develop a CDS system by using human-centered design (HCD) that identifies parents who smoke, provides motivational messages to quit smoking (informed by behavioral science), and supports delivery of evidence-based tobacco treatment. Methods Our multidisciplinary team applied a rigorous HCD process involving analysis of the work environment, user involvement in formative design, iterative improvements, and evaluation of the system's use in context with the following three cohorts: (1) parents who smoke, (2) pediatric clinicians, and (3) clinic staff. Participants from each cohort were presented with scenario-based, high-fidelity mockups of system components and then provided input related to their role in using the CDS system. Results We engaged 70 representative participants including 30 parents, 30 clinicians, and 10 clinic staff. A key theme of the design review sessions across all cohorts was the need to automate functions of the system. Parents emphasized a system that presented information in a simple way, highlighted benefits of quitting smoking, and allowed direct connection to treatment. Pediatric clinicians emphasized automating tobacco treatment. Clinical staff emphasized screening for parent smoking via several modalities prior to the patient's visit. Once the system was developed, most parents (80%) reported that it was easy to use, and the majority of pediatricians reported that they would use the system (97%) and were satisfied with it (97%). Conclusion A CDS system to support parental tobacco cessation in pediatric primary care, developed through an HCD process, proved easy to use and acceptable to parents, clinicians, and office staff. This preliminary work justifies evaluating the impact of the system on helping parents quit smoking.
Background With the widespread adoption of vendor-supplied electronic health record (EHR) systems, clinical decision support (CDS) customization efforts beyond those anticipated by the vendor may require the use of technologies external to the EHR such as web services. Pursuing such customizations, however, is not without risk. Validating the expected behavior of a customized CDS system in the high-volume, complex environment of the live EHR is a challenging problem. Objective This article identifies technology failures that impacted clinical care related to web service-based advanced custom CDS systems embedded in the complex sociotechnical context of a production EHR. Methods In an academic health system’s primary care network, we performed an inventory of incidents between January 1, 2008 and December 31, 2016 related to a customized CDS system and performed a targeted review of changes in the CDS source code. Additional feedback on the root cause of individual incidents was obtained through interviews with members of the CDS project teams. Results We identified five CDS malfunctions that impaired clinical workflow. The mechanisms for these failures are mapped to four characteristics of well-behaved applications: (1) system integrity; (2) data integrity; (3) reliability; and (4) scalability. Over the 9-year period, two malfunctions of the customized CDS significantly impaired clinical workflow for a total of 5 hours. Lesser impacts—loss of individual features with straightforward workarounds—arose from three malfunctions, which affected users on 53 days. Discussion Advanced customization of EHRs for the purpose of CDS can present significant risks to clinical workflow. Conclusion This case study highlights that advanced customization of CDS within a commercial EHR may support care for complex patient populations, but ongoing monitoring and support is required to ensure its safe use.
Background: Research is needed to identify how clinical decision support (CDS) systems can support communication about and engagement with tobacco use treatment in pediatric settings for parents who smoke. We developed a CDS system that identifies parents who smoke, delivers motivational messages to start treatment, connects parents to treatment, and supports pediatrician-parent discussion. Objective: To assess the performance of this system in clinical practice, including receipt of motivational messages and tobacco use treatment acceptance rates. Methods: The system was evaluated at one large pediatric practice through a single-arm pilot study from June-November 2021. We collected data on the performance of the CDS system for all parents. Additionally, we surveyed a sample of parents immediately after the clinical encounter who used the system and reported smoking. Measures were: 1) the parent remembered the motivational message, 2) the pediatrician reinforced the message, and 3) treatment acceptance rates. Treatments included nicotine replacement therapy, quitline referral (phone counseling), and/or SmokefreeTXT referral (text-message counseling). We described survey response rates overall and with 95% confidence intervals (CI). Results: During the entire study period, 8488 parents completed use of the CDS: 9.3% (n=786) reported smoking, and 48.2% (n=379) accepted at least one treatment. One hundred and two parents who smoke who used the system were approached to survey 100 parents (98% response rate). Most parents self-identified as female (84%), aged 25-34 years (56%), and Black/African American (94%), and had children with Medicaid insurance (95%). Of parents surveyed, 54% accepted at least one treatment option. Most parents recalled the motivational message (79%; 95% CI: 71-87%), and 31% (95% CI: 19-44%) reported the pediatrician reinforced the motivational message. Conclusion: A CDS system to support parental tobacco use treatment in pediatric primary care enhanced motivational messaging about smoking cessation and evidence-based treatment initiation.
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