DifferentUsersNeedDifferent ViewsofPa3entData By - - PowerPoint PPT Presentation

Different
Users
Need
Different
 Views
of
Pa3ent
Data



By
 Barbara
J.
Moore,
MD
 barbara_moore@vmed.org
 and
 Molly
Schaeffer,
MS
 mhschaeffer@alum.mit.edu


Mock
Ups



Clinician
Views
of
EMR
Data


Clinician
Views
of
EMR
Data


The
views
submiKed
for
clinicians
in
this
EMR
design
are
focused
on
ambulatory
visits
and
do
not
show
all
naviga3on
elements,
menus,
etc.
that
would
be
required
in
such
a
 system.
The
displays
are
intended
to
support
primary
care
clinicians
performing
chronic
disease
management.
The
design
targets
web
browsers
as
the
form
factor
(not
 mobile).
They
are
not
designed
for
acute
care
visits,
inpa3ent
encounters,
ICU
encounters,
acute
rehabilita3on
encounters,
etc.

In
keeping
with
user‐centered
design
(i.e.
 each
primary
user
has
his/her
own
view
of
the
data
to
match
that
user’s
mental
models
and
cogni3ve
needs),
the
views
support
percep3on,
cogni3on
and
situa3on
 awareness
for
the
primary
user,
the
clinician.
Thus,
the
mockup
views
that
follow
only
show
what
the
physician
or
advanced
prac3ce
clinician
would
work
with,
not
the
 views
that
other
staff
or
the
pa3ent
would
use.
The
display
is
data
source
agnos3c,
accep3ng
input
from
the
Pa3ent
Health
Record,
electronic
ques3onnaires
filled
out
by
 pa3ents
in
the
office,
data
from
outside
facili3es,
etc.,
in
order
to
enable
the
clinician
to
manage
the
visit
armed
with
necessary
informa3on
to
understand
the
pa3ent’s
 status
and
to
help
the
pa3ent
make
informed
decisions.
 Because
users
are
limited
in
the
number
of
items
they
can
keep
in
working
memory
and
their
cogni3ve
processing
is
disrupted
by
designs
that
require
them
to
interact
with
 mul3ple
screens
while
comple3ng
a
given
task,
the
views
that
follow
aKempt
to
enable
the
user
to
perform
most
of
the
visit’s
work
in
one
view.
When
required,
the
design
 uses
modeless
pop‐up
windows
to
display
addi3onal
informa3on
and
tasks
not
available
in
the
primary
window
and
enables
task
comple3on
in
that
pop‐up
window,
if
the
 task
can’t
be
completed
in
the
primary
window.
The
VA
has
successfully
demonstrated
this
method
of
task
comple3on.
When
EMRs
use
modal
pop‐up
windows,
clinician
 workflow
is
forced
to
stop,
because
the
work
in
the
supplemental
pop‐up
window
must
be
completed
immediately,
as
the
only
other
choice
is
for
the
clinician
to
 permanently
dismiss
the
window
in
order
to
con3nue
to
work.
Modeless
windows
allow
the
task
to
be
postponed
un3l
the
clinician’s
workflow
is
ready
to
handle
it
by
 minimizing
that
window
un3l
such
3me
as
the
clinician
is
ready
to
do
that
work.
Cues
must
be
provided
in
the
display
to
remind
the
user
that
minimized
windows
exist,
 before
the
visit
is
completed,
given
the
hazards
that
hidden
informa3on
may
be
forgoKen.
 Narra3ve
notes
support
clinician
cogni3on
when
reviewing
medical
records
and
also
help
clinicians’
cogni3ve
processing
during
visits.
This
design
would
translate
the
visit
 into
a
narra3ve
note
upon
comple3on
to
enhance
future
review
and
also
has
areas
for
the
user
to
include
narra3ve
input
during
the
visit,
regardless
of
user’s
input
device
 choice
–
speech,
keyboard,
etc.



 Providing
various
data
in
the
context
of
the
clinician’s
work
view,
such
as
lab
data
and
medica3ons,
will
help
support
the
clinician’s
comprehension
of
that
pa3ent’s
 situa3on,
while
minimizing
the
cost
to
working
memory
and
aiding
cogni3on.

Avoiding
cluKer
and
waste
in
the
display
by
focusing
only
on
the
necessary
elements
of
any
 given
lab
test
and
then
suppor3ng
cogni3on
by
indica3ng
whether
the
result
is
out
of
range
(color
and
asterisk
‐
including
superscript
loca3on
if
above
normal
range
and
 subscript
loca3on
if
below
normal
to
support
red‐green
color
blind
users),
displaying
arrows
to
indicate
recent
trends
of
data
if
more
than
one
data
point
is
available
 (increasing,
decreasing,
unchanged)
and
displaying
sparkline
graphs
of
data
trends
over
3me
also
will
help
enhance
the
clinician’s
efficient
understanding
of
the
pa3ent.

 Providing
real‐3me
alerts
and
warnings
at
appropriate
points
in
the
clinician’s
workflow
embedded
in
the
view
improves
clinician
efficiency.

For
example,
warning
the
 clinician
of
a
drug‐drug
interac3on
a]er
the
clinician
completes
inpu^ng
the
name
of
the
drug
being
ordered,
rather
than
wai3ng
to
present
this
informa3on
to
the
 clinician
only
a]er
the
clinician
has
completed
all
aspects
of
the
order
and
aKempts
to
sign
that
order
will
save
significant
3me.
Warning
the
clinician
that
a
drug
may
need
 dose
adjustment
based
on
recent
lab
results
supports
pa3ent
safety.

Drawing
clinician
aKen3on
to
possible
interpreta3on
of
lab
results
and
sugges3ng
further
evalua3on
 to
consider
within
the
work
view,
so
that
clinicians
don’t
need
to
go
to
the
desktop
or
new
browser
window
to
seek
help
in
decision‐making
would
also
improve
efficiency
 and
safety.


 The
underlined
blue
text
represents
hyperlinks.
The
black
inverted
triangles
represent
toggles
to
show/hide
the
panel
below
it.

One
op3on
that
would
enable
naviga3on
 around
the
EMR,
but
would
also
allow
a
glimpse
at
abbreviated
lists,
such
as
lab
tests
contained
in
the
system,
and
would
do
so
without
requiring
that
the
user
leaving
his
 work
display
to
look
at
that
sec3on
is
a
panel
that
can
be
shown
or
hidden
by
toggling
its
control
(in
this
example
a
buKon
is
used).




Current
Level
of
Control
:


(Y)
Not
well
Controlled


Item
















































Result



































Interpreta3on

























Trend
 
Day
Symptoms

 











>2
days/wk

























(Y)
Not
well
controlled
 
Night
Awakenings





















>2/mo



































(Y)
Not
well
controlled
 
Ac3vity
Limita3on





















None





































(G)
Well
controlled
 

SABA
use




































>2
days/wk


























(Y)
Not
well
controlled
 

FEV1/FVC
Actual/LLN















89
/
78


































(G)
Well
controlled
 

FEV1
%
predicted






















102
%




































(G)
Well
controlled














 

A.C.T.











































18











































(Y)
Not
well
controlled
 

Oral
Steroids






























0













































(G)
Well
controlled
 Hospitaliza3ons
/
ICU/Intub
.


0
/
0
/
0
 ED/UC/Acute
Office



















0
/
0
/
0
 School
days
missed




















4
 Gym
missed

































‐‐
 Parent
work
missed



















4
 Pa3ent
work
missed


















‐‐


Control
&
Trends:


Exercise
symptoms















Rare
cough
if
smog/cold
air/URI
 
Pre‐Exercise
Rx

(%
adher)


















Albuterol
only
if
URI

(33%)
 
Non‐pharmacologic
(%
adher)










Scarf
in
cold
air;
warm‐up
exercises,

 





















































avoid
outdoors
if
air
quality
bad
(25%)


Below
is
an
example
of
the
Control
&
Trend
sec3on
of
an
asthma
chronic
disease
management
encounter.

In
order
to
not
disadvantage
red‐green
color
blind
 clinician
users,
a
leKer
appears
in
parentheses
to

cue
those
users
(corresponding
to
green
zone,
yellow
zone
or
red
zone
for
that
item)
 Some
data
items
would
come
from
hospital
facili3es,
others
would
be
gathered
from
the
pa3ent
and
family
in
order
to
see
them
in
the
display.

Sparkline
graphs
 would
include
colored
backgrounds
indica3ng
the
data
that
places
the
pa3ent
in
the
green
zone,
yellow
zone
or
red
zone
of
asthma
control.

The
required
data
elements

 In
a
CCD
are
not
sufficient
to
provide
all
necessary
data
to
help
clinicians
be
efficient
and
effec3ve.


Below
is
an
example
of
an
alterna3ve
view
for
the
clinician’s
problem
list
that
can
be
built
as
an
interac3ve
treeview.

The
user
can
drill
into
a
given
node
to
 reveal
further
child
nodes
beyond
or
could
get
overview
details
at
a
given
node,
as
in
neuropathy
below.
This
would
aid
in
understanding
co‐morbid
 condi3ons.
This
would
be
a
supplemental
way
to
view
a
problem
list.

See
hKp://prefuse.org/gallery/treeview/
for
basic
treeview
informa3on.



Use
lab
displays
that
eliminate
unnecessary

data.


 Also,

display
data
aggregated
in
the
way
the
user
processes
them
cogni3vely,
rather
than
in
the
way
that
the
clinical
lab
reports
them.



WBC

8.7


P
59


B
1


L

36

M
1

Baso

1

E
2


ANC

2.5


AEC

0.4

 HB

10.2



RBC

3.9


MCV


72



RDW

17%




RBC
morphology:
anisocytosis,
hypochromic





 Plt


345




Plt
morphology

normal


References:
 Endsley,
M.
A.,
Bolte,
B.,
&
Jones,
D.
G.
(2003).
Designing
for
Situa3on
Awareness.
Boca
Raton,
FL,
USA:
CRC
Press.
 Patel,
V.
(1999)
What
is
wrong
with
EMR:
a
cogni3ve
perspec3ve.
Panel
Discussion
AMIA;
hKp://people.dbmi.columbia.edu/cimino/Presenta3ons/1999‐Scamc‐ What%20is%20Wrong%20with%20EMR.ppt;
retrieved
on
Oct
24th
2011.
 Nygren,
E.
and
Henriksson,
P.
(1992)
Reading
the
medical
record.
I.
Analysis
of
physicians’
ways
of
reading
the
medical
record.
Computer
Methods
and
Programs
 in
Biomedicine,
39,
1‐12.


Microcy3c
anemia,
Mentzer
index,
RBC
 morphology
and
RDW
 suggest
iron
deficiency.
Consider

 re3culocyte
&
iron
studies


Mock
Ups



For
Pa3ents,
Caregivers
and
Family
 members


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• 1%#$-&$7&$(#9$*3-"$&4$63/173-1&,$+'#,341&+;$$!"#$*3-1#,-5$.3%1/9$&4$'34#216#4$'3,$)*73-#$

7#%&243*"1'$3,7$+&'13/$1++)#+$+#'-1&,+;$$J#71'3-1&,+$34#$+"&0,$01-"$3$*"&-&5$:43,7$3,7$2#,#41'$ ,3%#+5$-"#$4#3+&,$-"#$%#71'3-1&,$03+$*4#+'41:#7$3,7$7&+1,2$1,.&4%3-1&,;$$K"3,2#+$3,7$ '&,-1,)3-1&,+$-&$%#71'3-1&,+$34#$#>*/31,#7$1,$4#/3-1&,$-&$4#'#,-$-#+-$4#+)/-+;$$!#+-$4#+)/-+$'3,$:#$ .1/-#4#7$:9$-1%#$*#41&7$&4$/1%1-#7$-&$&)-$&.$43,2#$4#+)/-+;$$C.$-"#$*"9+1'13,$"3+$%37#$'"3,2#+$-&$ %#71'3-1&,+$7)#$-&$&)-$&.$43,2#$4#+)/-+5$-"3-$1+$"12"/12"-#7$&,$-"#$-#+-$4#+)/-+$+'4##,;$$B$/1,($-3(#+$

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$

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the
dosage
when
you
receive
your
prescripNon.


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 Administra3ve
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1. Coumadin

(Generic:
Warfarin)
2.5
mg
daily

 2. Trilisate,
Tricosol
(Generic:

Choline,
Magnesium
 Salicylate)
750
mg
every
8
hours

 3. Prilosec,
Prilosec
OTC
(Generic:

Omeprazole)
one
 20
mg
capsule/day

 4. Pilocar
Pilocarpine
Ophthalmic
Solu3ons
Eye
Drops
 1
drop
in
each
eye
twice
a
day

 5. Paxil
(Generic:

Paroxe3ne)
20
mg
daily
 6. Capoten
(Generic:
Captopril)
25
mg
twice
a
day
 7. Fosamax
(Generic:

Alendronate)
5
or
10
mg
daily
 8. Lipitor
(Generic:

Atrovasta3n)
20
mg
daily
 CAUTION:

Never
take
aspirin
or
any
medica3ons
 containing
aspirin
while
taking
Coumadin
(Warfarin)
 because
aspirin
can
make
your
stomach
and
or
intes3nes
 bleed


SAVE
 QUIT


All
test
results,
except
HDL
and
LDL
cholesterol,
were
within
normal
range
at
last
visit
with
Lisa
Bingham,
MD
(PCP).

 Click
here
to
see
test
results.

Con3nue
ALL
the
medica3ons
listed
below.

PLEASE
NOTE:

Dr.
Bingham
has
 increased
the
amount
of
Lipitor
(AtrovastaNn)
you
should
be
taking.

You
will
see
a
change
in
the
dosage
when
you
 receive
your
prescripNon.


Alma
Roberts


Medica3ons


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&"$('*#

8"##@/*;*6(7.A#@/*0%6%;#,-.+./*01##$?%;*+.A#B(:+.6*&'# C(;*0<;(7.4# 5+67/&07*%+61#D9E#':#.F./<#G#?%&/6# # =.(6%+#3%/#7(>*+:#7?*6#'.)*0(7*%+1##+,-'#.,%/## H"##I/*;%6.0A#I/*;%6.0#J@$!"-.+./*01##J'.K/(L%;.4# 5+67/&07*%+61#%+.#8E#':#0(K6&;.M)(<# =.(6%+#3%/#7(>*+:#7?*6#'.)*0(7*%+1##0*&&*/#

.(&&%1%2%"3#()#45#12**6#7%8*/#8,$%(9&# 6$97#%/"*$,-"%(/&# # #

• 4. Pilocar Pilocarpine Ophthalmic Solutions Eye

Drops Instructions: 1 drop in each eye twice a day

=.(6%+#3%/#7(>*+:#7?*6#'.)*0(7*%+1##Glaucoma

• 5. Paxil (Generic: Paroxetine)

Instructions: 20 mg daily

=.(6%+#3%/#7(>*+:#7?*6#'.)*0(7*%+1##!/:%*"3#

• 6. Capoten (Generic: Captopril)

Instructions: 25 mg twice a day

# =.(6%+#3%/#7(>*+:#7?*6#'.)*0(7*%+1##High blood

pressure

• 7. Fosamax (Generic: Alendronate)

Instructions: 5 or 10 mg daily

=.(6%+#3%/#7(>*+:#7?*6#'.)*0(7*%+1#

;&"*(.($(&%&

G"#N*K*7%/#,-.+./*01##O7/%F(67(7*+4# 5+67/&07*%+61##8E#':#)(*;<# =.(6%+#3%/#7(>*+:#7?*6#'.)*0(7*%+1##<%7=#

• =(2*&"*$(2#

#$%&'()*!!)+,+-!./0+!/123-34!5-!/46! 7+839/.3541!954./3434:!/123-34!;<3=+! ./034:!#5>7/834!"?/-@/-34A!B+9/>1+! /123-34!9/4!7/0+!65>-!1.57/9<!/48!5-! 34.+1.34+1!B=++8!

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 Appointments
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 Future
Appointments
(click
an
appointment
to
change
or
cancel
it)
 1.

Th
11/28/12
9:30
a.m.

Lisa
Bingham,
MD
(PCP)


• 2. W
12/12/12
1:00
p.m.

Mark
Fitzgerald,
MD
(Cardiologist)

• 3. M

1/7/13

3:00
p.m.

Tina
Fordham,
DDS
(Den3st)


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DDS
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Home
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device
readings:
 Weight
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 Pedometer
trend
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diet
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 1
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beverage/day


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Click
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Click
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or
add
 items:
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 3. Transporta3on‐no
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 4. Low
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Click
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 contact
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send
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 Carla
Brown
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RN
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 Susan
Ford
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 Lisa
Bingham,
MD
(PCP)
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Fitzgerald,
MD
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Fordham,
DDS
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