User-centered design seeks to involve users at all stages of the design process, but the process itself can be tedious, leading to varying degrees of implementation among vendors. The evaluation includes a randomized controlled trial comparing the use of the new design platform with classic user-centered design techniques.
Abstract
Background
Users can express their preferences on the software's dynamic canvas, where the user interface is built. The user interacts with the controller to make changes to values in the underlying model, which are then reflected in the view on the canvas.
Results
A separate JSON preferences file allows the elements in the preference panel to be grouped into categories that can be directly accessed while the user builds the interface. This is possible because the platform itself only acts as a service interface to provide the canvas with the values in the preference panel.
Conclusions
The first use case demonstrates the effective use of AngularJS directives to customize the information displayed and the formatting of that information (available at https://vandaid.azurewebsites.net). For example, a user can select the electrolyte panel displayed in the list and then customize the presentation of the laboratory data by indicating whether or not out-of-range laboratories should be displayed in bold, and by indicating whether or not new laboratories should be shown in italics. . After using the tool, participants completed a usability survey of the system, which yielded an average result of 84.3 (95% CI, which puts it in the 96th percentile for usability with this standardized survey).
Funding
Involvement of the clinician end user is critical to the design of a successful neonatal delivery tool that integrates with the electronic health record. All artifacts created were collected by the design team at the end of the session.
Discussion
Compared to the PD session, using the VandAID tool was significantly faster and less burdensome for providers and researchers, while yielding similar results. Identification of items for the toolbox and design of the sample items was improved by having the expertise of an informatics trained user.
Acknowledgements
User-centered design seeks to involve end users in all stages of the design process in order to help build software that is best suited to the job at hand. One of the main goals of this research was to create a new method to involve multiple end users in remote user-centered design.
Core Functionality in Pediatric Electronic
Core Functionality in Pediatric Electronic Health Records
This report is based on research conducted by the Vanderbilt University Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. I). People using assistive technology may not be able to fully access the information in this report.
Preface
Acknowledgments
Key Informants
Peer Reviewers
Structured Abstract
Contents
Empirical data describing the specific benefits of pediatric EHRs are scarce, and few studies have been conducted in the pediatric setting to assess the potential benefits of pediatric research. While the Health Information Technology for Economic and Clinical Health (HITECH) Act has promoted EHR adoption by providers and hospitals, the development and implementation of functionality to promote the quality of pediatric care has been inconsistent, even among supporters of EHR implementation.45 Organizations, including the Agency for Healthcare Research and Quality (AHRQ),46 Health Level 7 (HL7) International,47 and AAP3 attempted to achieve consistency by describing data formats and desired features for use in pediatric EHRs.
Scope
The Children's EHR format included almost 700 requests related to pediatric functionality.46 While the report included desired functions to support pediatric care, the sheer number of requests may have had a paralyzing effect on vendors, who, too. Reports from Children's Health Insurance Reauthorization Act D beneficiaries indicate that vendors used a survey-based prioritization approach to identify high-value items.
Issues and Challenges in the Evidence Base
Technical Brief Objectives
Report Organization
GQ3. Description of the Existing Evidence
GQ4. Dissemination and Future Developments
We used discussions with key informants, a search of the gray literature, and a search of the published literature to gather relevant data and descriptions.
Data Collection
Discussions With Key Informants
Published Literature Search
To identify newly published relevant literature, we updated the literature search during the peer review and public comment posting period. Original research studies that provide sufficient detail regarding methods and results to enable use and adjustment of data and results.
Gray Literature Search
Data Organization and Presentation
In GQ2, we address contextual issues including transition of care, health care and implementation considerations from the literature base and key informant input. Based initially on input from key informants and with confirmation from the literature, we organize the report around eight categories for the pediatric functions: (1) vaccines; (2) routine health care maintenance; (3) family dynamics; (4) privacy; (5) management of pediatric.
Peer Review
We present tables and summary text to characterize the existing evidence for specific pediatric EHRs (GQ3). We emphasize the roles of testability and usability in the successful deployment and future development of pediatric-specific EHRs in GQ4.
Findings
GQ1: Description of Pediatric-Specific Functionalities for EHRs
Vaccines
Summary of Recommended Functionalities and Issues Identified by Key Informants
Summary of Recommended Functionalities and Issues Identified in the Literature
Efficient Recording of Vaccine Data
Clinical Decision Support
One study reported an increase in flu vaccination rates from 7.8 percent to 25.5 percent after implementing decision support in an EHR,57 and another reported an increase not only in immunization rates but also in the order of several other screening tests, which points to a possible spillover effect.58.
Immunization Status
Flexibility of Formats To Promote Data Sharing
User Perspective From AAP Review System
Routine Health Care Maintenance (RHCM)
The most widely used guidelines for pediatric preventive care are the Bright Futures Guidelines for the Health Surveillance of Infants, Children, and Adolescents.62 These emerged dominantly in both the literature and key informant discussions. As of 2008, no existing EHR was fully "bright future compatible." Since then, several products have implemented parts, but adoption has been slow.
User Perspective from AAP Review System
Family Dynamics
Privacy
Implementing the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 for “meaningful use” while protecting a patient's privacy could pose a potential conflict for both providers and EHR designers. Meaningful use regulations require reconciliation of medications, providing post-visit summaries, and generating lists of patients by condition.
Enable Default Privacy Settings for Adolescent Patients
Automatic publication of an explanation of benefits or a summary after the visit. Request for summary of care or copies of medical records11. These activities may result in a breach of confidentiality for adolescents, particularly if the results of such functions are automatically communicated to parents or insurance companies, resulting in the inadvertent disclosure of protected confidential health information. a young man.
Designate Individual EHR Items as Private
Studies have noted the use of clear on-screen labeling of sensitive data items to help facilitate the differentiated designation of sensitive items in an individual patient's record.70 While EHR designers will undoubtedly develop their own implementations of this functionality, suggested Anoshiravani et al. of a specific background color or opaque shading of confidential elements to clearly delineate the confidential status of the data element.
Transmit Privacy Settings With Information
Special Consideration to Proxy Access
Allow Differential Access to Protected Health Information
Managing Pediatric Conditions in Vulnerable Populations
Managing a Clinical Subpopulation
Medications
Key informants discussed the safety issues inherent in medication management and noted that the lack of such functionality increases a child's risk of receiving the wrong medication or the wrong dose. Key informants commented on the need for flexible systems with robust rules for features such as dose rounding that account for differences in patient populations and in the drugs being administered.
Medication Management
Electronic Prescribing
Documentation and Billing
Key informants also discussed the documentation of care in terms of the ability to identify previous visits and visits to other centers. Key informants also commented on the lack of consistent, common nomenclature for coding elements of care.
Pediatric-Specific Norms and Growth Charts
Several providers complained about EHR systems leading to workflow disruptions, with a focus on ease of documentation and note-taking. Other features of the documentation and workflow that reviewers mentioned include: 1) enabling patient documentation;
Sensitivity to Growth Norms
Flexibility in Data Formats
Flexible Growth Charts
Calculate average parent height by sex-specific parent height percentiles Display bone age measurements with actual age measurements. Display developmental states (eg Tanner stages) with current age measurements Define and display the average age at which a given growth point is reached Allow adding, deleting and editing growth points.
Subpopulation-Specific Growth Charts
Growth Monitoring Decision Support Tools
However, some reviewers reported using EHR systems that did not provide growth charts at all. As a key element in tracking a child's health and development, growth charts are of great concern to pediatricians.
GQ2. Description of the Context in Which EHRs Are Implemented
Age-Based Transitions
Specific EHR functions to support this transition thus depend on an EHR's ability to send, receive, integrate a patient's data, and prompt physicians to act on vaccine data, or lack thereof. In addition to vaccinations, preventive care information that is appropriate for the patient's age and developmental stage should be provided at each well visit.
Inpatient and Outpatient
Similar to asthma action plans, the literature search identified forms known as "emergency information forms" (EIFs), also known as an individualized care plan, as an important function to facilitate care transitions, especially among patient-centered medical home, specialty. services and acute care. The EIF is optimally designed in the patient-centered medical home for a child with specific or complex medical conditions to provide a minimal amount of data related to the diagnoses and medications the patient is also taking.
The Particular Challenge of Identity
A distinctive feature of a well-child visit is the degree to which it is highly structured. Ironically, implementing all of the features mentioned may actually present a challenge for pediatric providers to successfully screen enough patients while properly documenting and utilizing all of the features available in the EHR.
Vaccines
According to our Key Informants, any implementation of an EHR must take into account that pediatrics is a high-volume practice, and adding time and complexity to the day in an already relatively low-margin field will be problematic for physicians. Indeed, one study in our review documented the time it took for a pediatric practice to return to baseline volume after implementing an EHR, and it was much longer than the vendor had indicated.103.
Routine Health Care Maintenance
Key informants noted that taking the time to record additional information than could have previously been recorded comes at a potentially significant cost if it requires fewer visits to occur.
Privacy
Managing Pediatric Conditions in Vulnerable Populations
Medications
Documentation and Billing
Pediatric-Specific Norms and Growth Charts
GQ3. Evidence for Pediatric-Specific Functionalities (Evidence Map)
An AHRQ review broadly assessed pediatric health information technology and noted some evidence in support of CPOE and CDS from a small number of studies, mostly conducted in academic medical centers.116 Some studies reported improvements in documentation and. Evidence for changes in vaccine adherence was mixed, with small improvements in adherence to one vaccine in one study in a general pediatric population and improvements in influenza vaccine in children with asthma in another.
Vaccination-Specific Functionality
Updated on index birthday No clinically meaningful change. Interrupted time selected from 3 age delayed. Influenza vaccination rate (% . of non-up-to-date children vaccinated at visit) Reminder to: 76.2 Reminder from: 73.8 Documentation for lack of administration.
Medication-Specific Functionalities
McCrory et al., Patients in a PICU receiving manual red blood. Kadmon et al., 1250 orders each of CPOE with and without total errors, the 4 periods comprising the decision support.
Obesity Diagnosis
CPOE = computerized physician order entry; it = electronic health records; NICU = neonatal intensive care unit; PICU = pediatric intensive care unit. The predicted probability of an obesity diagnosis increased significantly more in the intervention group than in the control group.
Other Functionalities Including Prevention and Counseling
Physicians were more likely to screen for risk factors in the intervention group. 33% of eligible physicians in the intervention group used the ADHD template during the study period.
Ongoing Research
This study led to important findings for identifying risk factors for tuberculosis and iron deficiency anemia. In the intervention group, significantly more people reported positive risk factors for iron deficiency anemia compared to the control group (OR=6.6, 95% CI: 4.5 to 9.5).
Utility
Adding pediatric features to existing EHRs can have either a positive or negative effect on implementation success. Negative effects through additional pediatric functionalities may be associated with poor implementation in workflows, inclusion of functionalities that have little value to pediatric providers, and unintended consequences of new pediatric features such as increased documentation burden or increased responsibility.
Testability
How does the testability and usability of core functionalities promote or hinder the proliferation and future development of pediatric EHRs? There are a number of challenges associated with developing and implementing core functionalities for pediatric EHRs.
Usability
However, the usability of the functionalities was clearly presented as a high priority, and testing for usability can be difficult and time-consuming. It is clear from the comments provided on the AAP EMR review page that there is a difference in the perceived usability of basic functions across the spectrum of commercially available EMRs.
Specificity and Computability
One suggestion to increase the usability of new features was to recommend that vendors provide real-time, contextual support features to optimize the use of pediatric resources. The usability of EHR functionalities was recently assessed by AHRQ.142 In the adult literature, the usability of core functionalities has influenced EHR adoption and spread.
Incentives for Developing Pediatric Functionalities
Meaningful Use and the Patient-Centered Medical Home
Patient Safety
Clinical Quality Measures (CQMs)
Summary and Implications
At the macro scale, the EHR should support the management of clinical subpopulations by allowing the creation of customized lists based on condition or characteristic. The growth chart should be readily available in the EHR and should capture weight, height or height, head circumference, and calculate body mass index, growth velocity, percentiles, and standard deviations based on population norms.
Next Steps
Appendix A. Literature Search Strategies
Medline via PubMed
EMBASE
Appendix B. Key Informant Interviews
Appendix C. Summary of Key Informant Input
Appendix D. Screening Forms
Abstract Screening Form
Full Text Screening Form
Appendix E. Summary of Consensus Statements
A human factors guide to improving usability of critical user interactions when supporting pediatric patient care.
Appendix F. Ongoing Studies
Children's Hospital of Philadelphia (CHOP) Agency for Healthcare Research and Quality (AHRQ) Completed Start: December 2007. Children's Hospital of Philadelphia Agency for Healthcare Research and Quality (AHRQ) American Academy of Pediatrics DARTNet Institute Recruitment.
Appendix G. Reasons for Exclusion
