Estimating Cognitive Load in a Mobile Personal Health Record Application: A Cognitive Task Analysis Approach

Objectives Mobile health applications that are designed without considering usability criteria can lead to cognitive overload, resulting in the rejection of these apps. To avoid this problem, the user interface of mobile health applications should be evaluated for cognitive load. This evaluation can contribute to the improvement of the user interface and help prevent cognitive overload for the user. Methods In this study, we evaluated a mobile personal health records application using the cognitive task analysis method, specifically the goals, operators, methods, and selection rules (GOMS) approach, along with the related updated GOMS model and gesture-level model techniques. The GOMS method allowed us to determine the steps of the tasks and categorize them as physical or cognitive tasks. We then estimated the completion times of these tasks using the updated GOMS model and gesture-level model. Results All 10 identified tasks were split into 398 steps consisting of mental and physical operators. The time to complete all the tasks was 5.70 minutes and 5.45 minutes according to the updated GOMS model and gesture-level model, respectively. Mental operators covered 73% of the total fulfillment time of the tasks according to the updated GOMS model and 76% according to the gesture-level model. The inter-rater reliability analysis yielded an average of 0.80, indicating good reliability for the evaluation method. Conclusions The majority of the task execution times comprised mental operators, suggesting that the cognitive load on users is high. To enhance the application’s implementation, the number of mental operators should be reduced

How Do Clinical Information Systems Affect the Cognitive Demands of General Practitioners?: Usability Study with a Focus on Cognitive Workload

oai:ojs.hijournal.bcs.org:article/85Background Clinical information systems in the National Health Service do not need to conform to any explicit usability requirements. Poor usability can increase the mental workload experienced by clinicians and cause fatigue, increase error rates and impact the overall patient safety. Mental workload can be used as a measure of usability.Objective To assess the subjective cognitive workload experienced by general practitioners (GPs) with their systems. To raise awareness of the importance of usability in system design among users, designers, developers and policymakers.Methods We used a modified version of the NASA Task Load Index, adapted for web. We developed a set of common clinical scenarios and computer tasks on an online survey. We emailed the study link to 199 clinical commissioning groups and 1,646 GP practices in England. Results Sixty-seven responders completed the survey. The respondents had spent an average of 17 years in general practice, had experience of using a mean of 1.5 GP computer systems and had used their current system for a mean time of 6.7 years. The mental workload score was not different among systems. There were significant differences among the task scores, but these differences were not specific to particular systems. The overall score and task scores were related to the length of experience with their present system. Conclusion Four tasks imposed a higher mental workload on GPs: ‘repeat prescribing’, ‘find episode’, ‘drug management’ and ‘overview records’. Further usability studies on GP systems should focus on these tasks. Users, policymakers, designers and developers should remain aware of the importance of usability in system design.What does this study add?• Current GP systems in England do not need to conform to explicit usability requirements. Poor usability can increase the mental workload of clinicians and lead to errors.• Some clinical computer tasks incur more cognitive workload than others and should be considered carefully during the design of a system.• GPs did not report overall very high levels of subjective cognitive workload when undertaking common clinical tasks with their systems.• Further usability studies on GP systems should focus on the tasks incurring higher cognitive workload.• Users, policymakers, and designers and developers should remain aware of the importance of usability in system design.

Improving Usability and Adoption of Tablet-based Electronic Health Record (EHR) Applications

abstract: The technological revolution has caused the entire world to migrate to a digital environment and health care is no exception to this. Electronic Health Records (EHR) or Electronic Medical Records (EMR) are the digital repository for health data of patients. Nation wide efforts have been made by the federal government to promote the usage of EHRs as they have been found to improve quality of health service. Although EHR systems have been implemented almost everywhere, active use of EHR applications have not replaced paper documentation. Rather, they are often used to store transcribed data from paper documentation after each clinical procedure. This process is found to be prone to errors such as data omission, incomplete data documentation and is also time consuming. This research aims to help improve adoption of real-time EHRs usage while documenting data by improving the usability of an iPad based EHR application that is used during resuscitation process in the intensive care unit. Using Cognitive theories and HCI frameworks, this research identified areas of improvement and customizations in the application that were required to exclusively match the work flow of the resuscitation team at the Mayo Clinic. In addition to this, a Handwriting Recognition Engine (HRE) was integrated into the application to support a stylus based information input into EHR, which resembles our target users’ traditional pen and paper based documentation process. The EHR application was updated and then evaluated with end users at the Mayo clinic. The users found the application to be efficient, usable and they showed preference in using this application over the paper-based documentation.Dissertation/ThesisMasters Thesis Computer Science 201

Physicians and their Patience: Redefining Healthcare Relationships through Readability Optimization

The present study takes legibility research and extends it to the medical setting. Internal Medicine Physicians from UCF developed six passages of medical text detailing a History of Present Illness (HPI) Report from an emergency department as well as comprehension questions for the purpose of our study. In our study, we first presented non-medical passages and comprehension questions in six common fonts to identify participants\u27 individual fastest and slowest fonts. We then gave participants medical passages in both their best and worst fonts while measuring reading speed and comprehension. This study was delivered to a population of Amazon Mechanical Turk crowd workers to help us better understand how legibility improvements can be made within specific fields. We hope that with this study we can begin the process of restructuring Electronic Health Records to be more usable and efficient for physicians

Use of information systems as tools to improve and measure leadership skills acquisition through medical simulation

Background & Aims In a context of health care rising demands, paired with a pressure to reduce costs, doctors are now expected to be leaders in clinical and non-clinical settings, with different levels of responsibility. However, the majority of medical curricula do not include formal training in management and leadership. Undergraduate medical curricula are integrating advanced clinical simulation as a safe and reliable learning method. It usually represents the first opportunity for students to act as a team managing a critical situation, during which leadership skills are crucial. Most of simulations do not use electronic health records system (EHR), thus not providing training in this important field. This study aims to demonstrate how an information system can assist medical simulations, both as learning and assessment tools, in terms of leadership skills acquisition. Thus, it is intended to show how can leadership and management be taught using simulation and prove if it’s possible to introduce an information system to manage this process. By doing so, it might be possible to suggest a model of an integrated information system for teaching management and leadership. Materials & Methods A mixed methodology was used where two main research initiatives were combined. These took place in the Clinical Skills Lab of the Faculty of Health Sciences (University of Beira Interior), in Portugal. First, the author designed and developed a tool to simulate an electronic health records system, in tight collaboration with the Clinical Skills Lab. Then, using a triangulation model, an experiment was designed in the context of the Leadership and Management subject. Several simulation-based classes took place, with the purpose of training medical students in leadership. Data was collected and integrated with two survey data sets, quantitative information extracted from the EHR simulated system, as well as other qualitative data obtained or assessed by the author with the help of a video recording system. Results There were 16 teams/groups assessed, in a total of 85 students (aged between 21 and 36 years, average age of 23.4, standard deviation of 2.21. An important part of the data used for this study was obtained from the simulated EHR system, without whom it would not be possible to gather this study results. On efficiency metrics, teams took between 0 and 8 minutes to make the first interaction with the simulated EHR, took between 7 and 22 minutes to establish the correct diagnosis and took between 9 and 27 minutes to execute the desired therapeutically procedure. There were 2 groups who didn’t establish the correct diagnosis and consequently didn’t performed the desired clinical attitudes and additional plus two groups that also didn’t made the corrective therapeutic procedure. In average, each team made four complementary diagnostic test requisitions, registered 2,44 clinical history entries and listed in the system 74,3% of the executed procedures. Teams spent in average € 55,01, stated as real costs, in diagnostic tests. Considering leadership and teamwork competencies self-assessment, groups obtained an average global rate between 2,83 and 4,28, out of a Likert scale of 5 degrees. In a global external assessment on leadership skills, a total average of 3,43 e 3,33 was obtained, respectively, in a scale parallel to the one used in the self-assessment and in an additional questionnaire applied only during external analysis. 7 groups were categorized as having a direct leadership style, 4 as alternate, 3 as shared and 2 as chaotic. From the 85 students, 35 filled a two month post simulation survey. All the 35 students (100% of the responses) feel this simulation was useful in terms of leadership skills acquisition. 88,6% are interested in having access to their own session’s video recordings and 82,9% showed interest in having these sessions frequently. Discussion/conclusion It was possible to establish an association with time-related efficiency metrics with the leadership style present in each group. Groups categorized as chaotic did not reach a final diagnosis neither treat the simulated patient at their responsibility. The higher number of system interactions, sometimes repeated, can support the attribution of this categories to the groups. These number of interactions, in a real situation, could have brought higher costs to the team when compared with other teams categorized with the remaining three leadership styles. In a growing context of higher responsibility in healthcare worker’s leadership, as with a crescent technological development and also with a broader use of simulation as a learning methodology, simulation based leadership learning becomes mandatory. Teamwork and leadership does not occur spontaneously. It has to be learned and rehearsed and simulation is an excellent tool for teaching, rehearsing and analyzing team performance. Training is associated with timelier decision making as teams recognize critical events earlier and initiated interventions in a time critical manner. In fact, students claim to have learned by these simulation sessions.It is possible to introduce an information system to manage this process, providing such amount of useful data used in this study. Information systems give us the ability to improve quality of data and capacity to work on that data, extracting useful metrics and analysis. Despite the small sample of this study, differences were found regarding self-assessment and external assessment for chaotic groups, who rated themselves higher than the external observer did. Previously published results by Rudy et al. (2001) and Bryan et al. (2005) demonstrated that student leaders consistently scored themselves lower than their peers on many aspects of leadership, including altruism, compassion, integrity, accountability, commitment to excellence, and self-reflection. Leadership learning must start early on, in the context of higher education, and it must settle in well-structured curricula. With this strategy it will be possible to provide students with the necessary skills to become the doctors of tomorrow, in charge of multiple management activities, being clinical or non-clinical, and exceeding the challenges posed by globalized healthcare. This study showed the urgent necessity for the creation of systems that analyze training activities, around the clock and with powerful analytics engines. Such could allow prospective and retrospective studies based on clinical outcomes on a medium and long term.Contexto e objetivos Num contexto de crescimento nos gastos com a saúde, acompanhado por uma pressão para redução desses mesmos custos, espera-se hoje dos médicos que sejam lideres em ambiente clínico e não clínico, com diferentes graus de responsabilidade. Contudo, a maior parte dos curricula médicos não inclui o ensino formal da Liderança e Gestão em Saúde. Por outro lado, estes curricula pré-graduados incluem cada vez mais a simulação biomédica enquanto método de ensino seguro e viável. Estes momentos representam muitas vezes a primeira oportunidade para os estudantes de atuarem enquanto equipa, gerindo uma situação de crise, durante a qual as competências de liderança são cruciais. No entanto, a maior parte das simulações não usa um sistema de registos clínicos eletrónicos que seja auxiliar nestes cenários. Assim, pretende-se através deste estudo demonstrar como é que a Liderança e Gestão em Saúde pode ser ensinada recorrendo à simulação e provar a possibilidade de introduzir um sistema de informação para gerir este processo. Ao fazê-lo, será possível sugerir um modelo de sistema de informação integrado para o ensino desta área de ensino. Materiais e métodos Foi utilizada uma metodologia mista, tendo sido combinadas duas experiências de investigação. Estas tiveram lugar no Laboratório de Competências da Faculdade de Ciências da Saúde da Universidade da Beira Interior, em Portugal. Em primeiro lugar, o autor concebeu e desenvolveu uma ferramenta para simular um software de registos clínicos eletrónicos. Depois, utilizando um modelo de triangulação, foi desenhada uma investigação no contexto do modulo de Liderança e Gestão em Saúde desta faculdade. Diversas sessões de simulação foram levadas a cabo, com o propósito de treinar as competências de liderança e trabalho em equipa. Foi recolhida e integrada informação de diversas fontes, nomeadamente de dois questionários, informação quantitativa do sistema de registos clínicos simulado, bem como de avaliação qualitativa dos vídeos gravados das sessões Resultados Foram avaliadas 16 equipas, num total de 85 estudantes (com idades compreendidas entre os 21 e os 36 anos, média de idades de 23,4, desvio padrão de 2,21). Uma componente importante da informação utilizada neste estudo foi obtida pelo sistema de registos clínicos simulado, sem o qual não teria sido possível recolher estes dados em qualidade e quantidade. Em termos de métricas de eficiência, as equipas levaram entre 0 a 8 minutos para interagirem pela primeira vez com o sistema, entre 7 a 22 minutos para estabelecer um diagnóstico correto para o paciente simulado e entre 9 e 27 minutos para executar o procedimento terapêutico de correção. Houve dois grupos que não estabeleceram o diagnóstico correto e consequentemente não efetuaram a terapêutica adequada. Em média, cada equipa fez quarto requisições de métodos complementares de diagnóstico, registou 2,44 entradas de história clínica e listou no sistema 74,3% dos procedimentos efetuados ao paciente. As equipas gastaram uma média de € 55,01 em métodos complementares de diagnóstico, quando traduzido em custo real. Considerando a autoavaliação de competências de liderança e gestão em equipa, os grupos obtiveram uma classificação média global entre 2,83 e 4,28, de uma escala de Likert de 5 graus. Numa avaliação externa global às competências de liderança dos grupos, obteve-se uma média de 3,43 e 3,33, respetivamente, recorrendo à mesma escala usada pelos estudantes e aplicando uma escalada adicional desenvolvida para o observador externo. 7 grupos foram classificados por este observador como tendo um estilo de liderança vertical, 4 foram classificados como alternantes, 3 com liderança partilhada e 2 como caóticos. Do total de 85 estudantes, 35 preencheram um inquérito dois meses após a simulação. Todos os 35 estudantes (100% das respostas) sentiram que a simulação foi útil em termos de aquisição de competências de liderança e gestão. 88,6% estão interessados em ver as suas gravações de vídeo e 82,9% gostariam de ter este tipo de sessões de forma regular e frequente. Discussão/conclusões Foi possível estabelecer uma associação entre as métricas de tempo/eficiência com os estilos de liderança presentes em cada grupo. Equipas categorizadas como caóticas não chegaram a um diagnóstico final nem foram capazes de efetuar o procedimento terapêutico adequado. O maior número de interações com o sistema de registos, algumas delas repetidas, poderão suportar a atribuição destas categorias às equipas. Este número de interações, num contexto real, poderia ter sido traduzido em custos superiores, quando comparado com outros estilos de liderança que não o caótico. Numa realidade de responsabilização dos profissionais de saúde em funções de liderança, pareado com um crescente desenvolvimento tecnológico, bem como com uma utilização global da simulação enquanto ferramenta de ensino, o ensino da liderança recorrendo à simulação torna-se emergente e necessário. Liderança e trabalho de equipa não se adquirem espontaneamente. Estes devem ser aprendidos e treinados, sendo a simulação uma ferramenta crucial para tal. A prática está associada a melhores e mais rápidas decisões, dado que as equipas passam a reconhecer mais cedo os eventos críticos e iniciam ações em resposta a estes. De facto, os estudantes indicam ter desenvolvido competências de liderança através destas simulações. É possível introduzir um sistema de informação para gerir este processo, providenciando um enorme conjunto de dados, como os que foram utilizados neste estudo. Os sistemas de informação possibilitam a melhoria da qualidade dos dados e a capacidade para os analisar, extraindo métricas e análises relevantes, que não seriam obtidas de outra forma. Apesar da amostra pequena deste estudo, foram encontradas diferenças relativamente à autoavaliação e heteroavaliação de grupos caóticos, que atribuíram classificações superiores a si próprios, quando comparados com a heteroavaliação efetuada por observador externo. Como sugerido por Rudy et. Al (2001) e Bryan et al. (2005), está demonstrado que estudantes com boas capacidades de liderança tendem a ser mais autocríticos na altura de se autoavaliarem. A aprendizagem da liderança deve começar cedo, em ambiente universitário, e deve assentar em programas curriculares bem estruturados. Com esta estratégia, será possível enriquecer os estudantes com as competências necessárias para se tornarem os médicos do futuro, a cargo de múltiplas tarefas de gestão — clínicas ou não clínicas — ultrapassando os desafios colocados por uma saúde globalizada. Este estudo demonstra a necessidade urgente de criar sistemas de informação integrados para monitorizar tais atividades de ensino, em tempo real, com potentes ferramentas de análise. Tal poderá permitir estudos retrospetivos e prospetivos, baseados em resultados clínicos ou outros, de médio e longo termos

Interface Redesign of an Electronic Medical Record Review System Using User-Centered Design

The healthcare industry in recent years has seen a rise in the adoption of Electronic Medical Records (EMRs). These EMRs have replaced the traditional paper-based records at hospitals, clinics, and nursing facilities. This transition has brought with it, numerous advantages of digitization such as improved patient care, timely reminders for checkups, and better health data tracking over time. But the EMR adoption has also come with its own set of challenges. The EMR systems are maintained by the medical coders/nurses at the hospitals. The coders are expected to gather information from different sources such as patient history logs, test results from different labs, etc. followed by entry into the EMR system. Due to the unstructured nature of the task, data entry in EMRs is susceptible to errors which lead to the poor data quality of patient records. Diagnostic decisions taken by the medical practitioners based on erroneous data can adversely affect the patient and at times, even prove to be fatal. To help address this issue of poor data quality of System X, an EMR, employs a unique data review process which allows reviewers (domain experts) to check patient records and communicate back the data entry errors to the coders for required changes to ensure high data quality. In this research, the user-centered design methodology was applied to improve the review process, with the aim of facilitating easier and quicker workflow. The usability issues faced by the reviewers were identified through heuristic evaluations, video walkthroughs, and user interviews methods. To address the issues identified, a new interface design was developed by employing low fidelity and high-fidelity prototyping techniques. Involvement of the reviewers throughout the research ensured that the design proposed was continually assessed and improved qualitatively until they were satisfied. Lastly, the Keystroke Level Model (KLM) was used to quantitatively assess the performance improvement gained from the new design. The final interface design was able to reduce the task-execution time of the patient record review process by 28.51%. This resulted in saving a significant amount of the reviewer’s time, thereby reducing their workload while improving data quality

Perceptions of online information privacy among individuals with Parkinson\u27s Disease

The growth in Internet use for health care is paralleled by the increase in chronic health conditions such as Parkinson’s disease (PD). This study explores the perceptions o f online privacy held by individuals with PD. Ten individuals with PD participated in hour-long, semi- structured, in-person interviews. Analysis of the transcripts yielded four major themes regarding participant perceptions: (1) online information privacy, including discussions o f private information, exceptions, and anonymity; (2) media, family, and friends as sources o f knowledge about online information safety; (3) reasons for privacy concerns, including physical vulnerability, the lack o f ‘people’ on the Internet, and attitudes toward privacy and disclosure; and, (4) non-privacy related reasons for non-use o f Internet resources. Highlighted aspects o f participant perceptions include: lack o f awareness concerning privacy legislation and online PD communities, the perceived value of online resources as factual not supportive, and inability to form bonds of trust in online relationships

Modeling Clinicians’ Cognitive and Collaborative Work in Post-Operative Hospital Care

abstract: Clinicians confront formidable challenges with information management and coordination activities. When not properly integrated into clinical workflow, technologies can further burden clinicians’ cognitive resources, which is associated with medical errors and risks to patient safety. An understanding of workflow is necessary to redesign information technologies (IT) that better support clinical processes. This is particularly important in surgical care, which is among the most clinical and resource intensive settings in healthcare, and is associated with a high rate of adverse events. There are a growing number of tools to study workflow; however, few produce the kinds of in-depth analyses needed to understand health IT-mediated workflow. The goals of this research are to: (1) investigate and model workflow and communication processes across technologies and care team members in post-operative hospital care; (2) introduce a mixed-method framework, and (3) demonstrate the framework by examining two health IT-mediated tasks. This research draws on distributed cognition and cognitive engineering theories to develop a micro-analytic strategy in which workflow is broken down into constituent people, artifacts, information, and the interactions between them. It models the interactions that enable information flow across people and artifacts, and identifies dependencies between them. This research found that clinicians manage information in particular ways to facilitate planned and emergent decision-making and coordination processes. Barriers to information flow include frequent information transfers, clinical reasoning absent in documents, conflicting and redundant data across documents and applications, and that clinicians are burdened as information managers. This research also shows there is enormous variation in how clinicians interact with electronic health records (EHRs) to complete routine tasks. Variation is best evidenced by patterns that occur for only one patient case and patterns that contain repeated events. Variation is associated with the users’ experience (EHR and clinical), patient case complexity, and a lack of cognitive support provided by the system to help the user find and synthesize information. The methodology is used to assess how health IT can be improved to better support clinicians’ information management and coordination processes (e.g., context-sensitive design), and to inform how resources can best be allocated for clinician observation and training.Dissertation/ThesisDoctoral Dissertation Biomedical Informatics 201

The adoption of ICT in Malaysian public hospitals: the interoperability of electronic health records and health information systems

There have been a number of researches that investigated ICT adoption in Malaysian healthcare. With the small number of hospitals that adopt ICT in their daily clinical and administrative operations, the possibility to enable data exchange across 131 public hospitals in Malaysia is still a long journey. In addition to those studies, this research was framed under six objectives, which aim to critically review existing literature on the subject matter, identify barriers of ICT adoption in Malaysia, understand the administrative context during the pre and post-ICT adoption, and recommend possible solutions to the Ministry of Health of Malaysia (MoHM) in its efforts to implement interoperable electronic health records (EHR) and health information systems (HTIS). Specifically, this research aimed to identify the factors that had significant impacts to the processes of implementing interoperable EHR and HTIS by the MoHM. Furthermore, it also aimed to propose relevant actors who should involve in the implementation phases. These factors and actors were used to develop a model for implementing interoperable EHR and HTIS in Malaysia. To gather the needed data, series of interviews were conducted with three groups of participants. They were ICT administrators of MoHM, ICT and medical record administrators of three hospitals, and physicians of three hospitals. To ensure the interview feedback was representing the context of EHR and HTIS implementation in Malaysia, two hospital categories were selected, which included the hospitals with HTIS and non-HTIS hospitals. The government documents were then used to triangulate the feedback to ensure dependability, credibility, transferability and conformity of the findings. Two techniques were used to analyse the data, which were thematic analysis and theme matching. These two techniques were modified from its original method, known as pattern matching. The originality of this research was presented in the findings and methods to transform them into solutions and provide recommendation to the MoHM. In general, the results showed that the technological factors contributed less to the success of the implementation of interoperable EHR and HTIS compared to the managerial and administrative factors. Four main practical and social contributions were identified from this research, which included synchronisation of managerial elements, political determination and change management transformation, optimisation of use of existing legacy system (Patient Management System) and finally the roles of actors. Nevertheless, the findings of this research would be more dependable and transferable if more participants had been willing to participate especially among the physicians and those who managed the ICT adoptions under the MoHM

Web-based system for outcome analysis and modification in laser vision correction

Refractive laser eye surgery is a specialised field in ophthalmology which aims to correct the refractive disorder of an eye. The most established technique is LASIK, which has shown good results for the treatment of simple myopia. Complex refractive disorders, such as compound myopic astigmatism, have shown less predictable refractive outcomes, and in some cases the severe over- or under-correction can even worsen the preoperative situation and damage the eye. In its first stage, this research aimed to develop a software system able to present and analyse refractive outcomes. Over 2 prototype stages, this research has led to an operational system named IBRA (Internet Based Refractive Analysis), offering web-based data collection and refractive and vector analysis. In a second stage, Nomogram calculation formulas were developed and integrated into IBRA. These formulas were created from linear regression and best-fit analyses of spherical and cylindrical outcome data stored in IBRA. The purpose of the nomogram calculations was to provide surgeons with adjustment factors that could be used to improve the refractive outcome of patients with complex refractive disorders. Two extensive clinical audits and a randomized controlled trial were performed at Moorfields Eye Hospital to evaluate the IBRA nomogram adjustments. This research showed that IBRA was able to achieve a positive health change. In addition, results from the audits and trial contributed to the knowledge of nomogram adjustments and provided a framework in which future investigations on nomogram and treatment modifications could be performed. In addition to the above clinical studies, two evaluations were performed with the use of IBRA and data logging techniques to investigate users‟ behaviour relating to the management of data entry processes and the use of analysis functions. This research revealed the best method for entering refractive data, and was able to identify the most important analysis methods. Finally, the use of IBRA and its user-interface were investigated with a user satisfaction survey. The results from this questionnaire based study showed a high acceptance of the web-based platform of IBRA and indicated points for improvement (Documentation)