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Objective: To assess the impact of patient health literacy, numeracy, and graph literacy on perceptions of hypertension control using different forms of data visualization.Materials and Methods: Participants (Internet sample of 1079 patients with hypertension) reviewed 12 brief vignettes describing a fictitious patient; each vignette included a graph of the patient's blood pressure (BP) data. We examined how variations in mean systolic blood pressure, BP standard deviation, and form of visualization (eg, data table, graph with raw values or smoothed values only) affected judgments about hypertension control and need for medication change. We also measured patient's health literacy, subjective and objective numeracy, and graph literacy.Results: Judgments about hypertension data presented as a smoothed graph were significantly more positive (ie, hypertension deemed to be better controlled) then judgments about the same data presented as either a data table or an unsmoothed graph. Hypertension data viewed in tabular form was perceived more positively than graphs of the raw data. Data visualization had the greatest impact on participants with high graph literacy.Discussion: Data visualization can direct patients to attend to more clinically meaningful information, thereby improving their judgments of hypertension control. However, patients with lower graph literacy may still have difficulty accessing important information from data visualizations.Conclusion: Addressing uncertainty inherent in the variability between BP measurements is an important consideration in visualization design. Well-designed data visualization could help to alleviate clinical uncertainty, one of the key drivers of clinical inertia and uncontrolled hypertension. [ABSTRACT FROM AUTHOR]

THE INNOVATION We developed an innovative approach to peer-to-peer sharing of best practices using the Electronic Medical Record (EMR). Why? The challenges of EMR training are twofold: (1) even the [...]

Objective. Uncontrolled hypertension is driven by clinical uncertainty around blood pressure data. This research sought to determine whether decision support—in the form of enhanced data visualization—could improve judgments about hypertension control. Methods. Participants (Internet sample of patients with hypertension) in 3 studies (N = 209) viewed graphs depicting blood pressure data for fictitious patients. For each graph, participants rated hypertension control, need for medication change, and perceived risk of heart attack and stroke. In study 3, participants also recalled the percentage of blood pressure measurements outside of the goal range. The graphs varied by systolic blood pressure mean and standard deviation, change in blood pressure values over time, and data visualization type. Results. In all 3 studies, data visualization type significantly affected judgments of hypertension control. In studies 1 and 2, perceived hypertension control was lower while perceived need for medication change and subjective perceptions of stroke and heart attack risk were higher for raw data displays compared with enhanced visualization that employed a smoothing function generated by the locally weighted smoothing algorithm. In general, perceptions of hypertension control were more closely aligned with clinical guidelines when data visualization included a smoothing function. However, conclusions were mixed when comparing tabular presentations of data to graphical presentations of data in study 3. Hypertension was perceived to be less well controlled when data were presented in a graph rather than a table, but recall was more accurate. Conclusion. Enhancing data visualization with the use of a smoothing function to minimize the variability present in raw blood pressure data significantly improved judgments about hypertension control. More research is needed to determine the contexts in which graphs are superior to data tables. [ABSTRACT FROM AUTHOR]

Objective: Most electronic health records display historical medication information only in a data table or clinician notes. We designed a medication timeline visualization intended to improve ease of use, speed, and accuracy in the ambulatory care of chronic disease.Materials and Methods: We identified information needs for understanding a patient medication history, then applied human factors and interaction design principles to support that process. After research and analysis of existing medication lists and timelines to guide initial requirements, we hosted design workshops with multidisciplinary stakeholders to expand on our initial concepts. Subsequent core team meetings used an iterative user-centered design approach to refine our prototype. Finally, a small pilot evaluation of the design was conducted with practicing physicians.Results: We propose an open-source online prototype that incorporates user feedback from initial design workshops, and broad multidisciplinary audience feedback. We describe the applicable design principles associated with each of the prototype's key features. A pilot evaluation of the design showed improved physician performance in 5 common medication-related tasks, compared to tabular presentation of the same information.Discussion: There is industry interest in developing medication timelines based on the example prototype concepts. An open, standards-based technology platform could enable developers to create a medication timeline that could be deployable across any compatible health IT application.Conclusion: The design goal was to improve physician understanding of a patient's complex medication history, using a medication timeline visualization. Such a design could reduce temporal and cognitive load on physicians for improved and safer care. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to determine the information needs of primary care patients as they review clinic visit notes to inform information that should be contained in an after-visit summary (AVS).Method: We collected data from 15 patients with an acute illness and 14 patients with a chronic disease using semi-structured interviews. The acute patients reviewed seven major sections, and chronic patients reviewed eight major sections of a simulated, but realistic visit note to identify relevant information needs for their AVS.Results: Patients in the acute illness group identified the Plan, Assessment and History of Present Illness the most as important note sections, while patients in the chronic care group identified Significant Lab Data, Plan, and Assessment the most as important note sections.Discussion: This study was able to identify primary care patients' information needs after clinic visit. Primary care patients have information needs pertaining to diagnosis and treatment, which may be the reason why both patient groups identified Plan and Assessment as important note sections. Future research should also develop and assess an AVS based on the information gathered in this study and evaluate its usefulness among primary care patients.Practice Implications: The results of this study can be used to inform the development of an after-visit summary that assists patients to fully understand their treatment plan, which may improve treatment adherence. [ABSTRACT FROM AUTHOR]

To synthesize findings from previous studies assessing information needs of primary care patients on the Internet and other information sources in a primary care setting. A systematic review of studies was conducted with a comprehensive search in multiple databases including OVID MEDLINE, CINAHL, and Scopus. The most common information needs among patients were information about an illness or medical condition and treatment methods, while the most common information sources were the Internet and patients’ physicians. Overall, patients tend to prefer the Internet for the ease of access to information, while they trust their physicians more for their clinical expertise and experience. Barriers to information access via the Internet include the following: socio-demographic variables such as age, ethnicity, income, education, and occupation; information search skills; and reliability of health information. Conclusion: Further research is warranted to assess how to create accurate and reliable health information sources for both Internet and non-Internet users. [ABSTRACT FROM AUTHOR]

The article presents a study which compares the accuracy of diabetes dashboard screen and conventional approach in accessing multiple electronic health record (EHR) for high-quality diabetes care. The time, accuracy, and number of mouse clicks were measured while 10 primary care physicians searched their EHR using dashboard and conventional approach. Results show that dashboard screen is the most accurate because 100% of the data requested was identified correctly with 3 clicks in the mouse.

Background: Uncontrolled hypertension is a significant health problem in the United States, even though multiple drugs exist to effectively treat this chronic disease.Objective: As part of a larger project developing data visualizations to support shared decision making about hypertension treatment, we conducted a series of studies to understand how perceptions of hypertension control were impacted by data variations inherent in the visualization of blood pressure (BP) data.Methods: In 3 Web studies, participants (internet sample of patients with hypertension) reviewed a series of vignettes depicting patients with hypertension; each vignette included a graph of a patient's BP. We examined how data visualizations that varied by BP mean and SD (Study 1), the pattern of change over time (Study 2), and the presence of extreme values (Study 3) affected patients' judgments about hypertension control and the need for a medication change.Results: Participants' judgments about hypertension control were significantly influenced by BP mean and SD (Study 1), data trends (whether BP was increasing or decreasing over time-Study 2), and extreme values (ie, outliers-Study 3).Conclusions: Patients' judgment about hypertension control is influenced both by factors that are important predictors of hypertension related-health outcomes (eg, BP mean) and factors that are not (eg, variability and outliers). This study highlights the importance of developing data visualizations that direct attention toward clinically meaningful information. [ABSTRACT FROM AUTHOR]

The article discusses some of the challenges associated with making electronic health record (EHR) notes more readable as well as some of the ways in which they can be made easier to read, assimilate and use. The main challenge is that EHR notes try to meet the needs try to meet the needs of too many stakeholders and all foreseeable tasks. The need should be to provide readers with what they need, when they need it, and nothing more. The EHR should be seen to have 6 layers to be effective.

The article relates initial approaches that should be adopted by physicians to patients presenting with fatigue. Since half of the patients presenting with fatigue have a psychological cause, physicians should perform a physical examination, take a thorough history, and screen patients for depression using a validated primary care instrument, such as the Beck Depression Inventory or Prime-MD. They may also consider a directed laboratory evaluation with sedimentation rate, blood count, and glycohemoglobin and thyroid stimulating hormone levels, particularly in older patients.

The article offers a way to use smartphone (iPhone or Android) technology to avoid expense and delay while documentation in the electronic health record (EHR).

Objectives: Poor electronic health record (EHR) usability is associated with patient safety concerns, user dissatisfaction, and provider burnout. EHR certification requires vendors to perform user testing. However, there are no such requirements for site-specific implementations. Health care organizations customize EHR implementations, potentially introducing usability problems. Site-specific usability evaluations may help to identify these concerns, and "discount" usability methods afford health systems a means of doing so even without dedicated usability specialists. This report characterizes a site-specific discount user testing program launched at an academic medical center. We describe lessons learned and highlight three of the EHR features in detail to demonstrate the impact of testing on implementation decisions and on users., Methods: Thirteen new EHR features which had already undergone heuristic evaluation and iterative design were evaluated over the course of three user test events. Each event included five to six users. Participants used think aloud technique. Measures of user efficiency, effectiveness, and satisfaction were collected. Usability concerns were characterized by the type of usability heuristic violated and by correctability., Results: Usability concerns occurred at a rate of 2.5 per feature tested. Seventy percent of the usability concerns were deemed correctable prior to implementation. The first highlighted feature was moved to production despite low single ease question (SEQ) scores which may have predicted its subsequent withdrawal from production based on post implementation feedback. Another feature was rebuilt based on usability findings, and a new version was retested and moved to production. A third feature highlights an easily correctable usability concern identified in user testing. Quantitative usability metrics generally reinforced qualitative findings., Conclusion: Simplified user testing with a limited number of participants identifies correctable usability concerns, even after heuristic evaluation. Our discount usability approach to site-specific usability has a role in implementations and may improve the usability of the EHR for the end user., Competing Interests: The authors declare that they have no conflict of interest or competing interests in the project. MU Health Care was responsible for all aspects of testing and did not receive support, training, or other assistance from the EHR vendor. B.R. is employed by Cerner Corporation, the vendor, but her sole responsibilities are for the MU Health Care site-specific implementation., (Thieme. All rights reserved.)

Objectives: Improving the usability of electronic health records (EHR) continues to be a focus of clinicians, vendors, researchers, and regulatory bodies. To understand the impact of usability redesign of an existing, site-configurable feature, we evaluated the user interface (UI) used to screen for depression, alcohol and drug misuse, fall risk, and the existence of advance directive information in ambulatory settings., Methods: As part of a quality improvement project, based on heuristic analysis, the existing UI was redesigned. Using an iterative, user-centered design process, several usability defects were corrected. Summative usability testing was performed as part of the product development and implementation cycle. Clinical quality measures reflecting rolling 12-month rates of screening were examined over 8 months prior to the implementation of the redesigned UI and 9 months after implementation., Results: Summative usability testing demonstrated improvements in task time, error rates, and System Usability Scale scores. Interrupted time series analysis demonstrated significant improvements in all screening rates after implementation of the redesigned UI compared with the original implementation., Conclusion: User-centered redesign of an existing site-specific UI may lead to significant improvements in measures of usability and quality of patient care., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Cluttered documentation may contribute adversely to physician readers' cognitive load, inadvertently obscuring high-value information with less valuable information. We test the hypothesis that a novel, collapsible assessment, plan, subjective, objective (APSO) note design would be faster, more accurate, and more satisfying to use than a conventional electronic health record (EHR) subjective, objective, assessment, plan (SOAP) note for finding information needed for ambulatory chronic disease care., Methods: We iteratively developed physician clinic note prototypes with features designed to emphasize more important information and de-emphasize less clinically relevant information. Sixteen primary care physicians reviewed comparable clinic notes with the 4 note styles presented in random order to find key information in the notes during timed tasks. The 4 note styles were denoted A (traditional SOAP note), B (2-column APSO note), C (collapsible APSO note), and D (2-column collapsible APSO note). The 4 unique note styles were designed to have equal amounts of information in each section. We simulated their utility for clinical practice by imposing time limits and by interrupting 1 of the tasks with a typical clinical interruption. For each session, we recorded audio, computer-screen activity, eye tracking, and made field notes. We obtained usability ratings (System Usability Scale), new feature preference ratings, and performed semistructured post-task interviews with subsequent content analysis. We compared the effectiveness of the 4 note styles by measuring time on task, task success (accuracy), and effort as measured by NASA Task Load Index., Results: Note styles C and D were significantly faster than A and B for the Review of Systems and Physical Examination tasks, as we expected. Notes B and C had the best success (finding requested data) scores. Users strongly endorsed all the new note features incorporated into the new note prototypes. Previously expressed concerns about temporarily hiding parts of the note (using the accordion display design pattern) were allayed. Usability ratings for note A were worst but comparably better for note styles B, C, and D., Discussion: The new APSO note prototypes performed better than the traditional SOAP note format for speed, task success (accuracy), and usability for physician users acquiring information needed for a typical chronic disease visit in primary care. Moving Assessment and Plan to the top is 1 easily accomplished feature change. Innovative documentation displays of EHR data can safely improve information display without eliminating data from the record of the visit., Competing Interests: Conflict of interest: none declared., (© Copyright 2017 by the American Board of Family Medicine.)

Background: Electronic health records (EHRs) with poor usability present steep learning curves for new resident physicians, who are already overwhelmed in learning a new specialty. This may lead to error-prone use of EHRs in medical practice by new resident physicians., Objective: The study goal was to determine learnability gaps between expert and novice primary care resident physician groups by comparing performance measures when using EHRs., Methods: We compared performance measures after two rounds of learnability tests (November 12, 2013 to December 19, 2013; February 12, 2014 to April 22, 2014). In Rounds 1 and 2, 10 novice and 6 expert physicians, and 8 novice and 4 expert physicians participated, respectively. Laboratory-based learnability tests using video analyses were conducted to analyze learnability gaps between novice and expert physicians. Physicians completed 19 tasks, using a think-aloud strategy, based on an artificial but typical patient visit note. We used quantitative performance measures (percent task success, time-on-task, mouse activities), a system usability scale (SUS), and qualitative narrative feedback during the participant debriefing session., Results: There was a 6-percentage-point increase in novice physicians' task success rate (Round 1: 92%, 95% CI 87-99; Round 2: 98%, 95% CI 95-100) and a 7-percentage-point increase in expert physicians' task success rate (Round 1: 90%, 95% CI 83-97; Round 2: 97%, 95% CI 93-100); a 10% decrease in novice physicians' time-on-task (Round 1: 44s, 95% CI 32-62; Round 2: 40s, 95% CI 27-59) and 21% decrease in expert physicians' time-on-task (Round 1: 39s, 95% CI 29-51; Round 2: 31s, 95% CI 22-42); a 20% decrease in novice physicians mouse clicks (Round 1: 8 clicks, 95% CI 6-13; Round 2: 7 clicks, 95% CI 4-12) and 39% decrease in expert physicians' mouse clicks (Round 1: 8 clicks, 95% CI 5-11; Round 2: 3 clicks, 95% CI 1-10); a 14% increase in novice mouse movements (Round 1: 9247 pixels, 95% CI 6404-13,353; Round 2: 7991 pixels, 95% CI 5350-11,936) and 14% decrease in expert physicians' mouse movements (Round 1: 7325 pixels, 95% CI 5237-10,247; Round 2: 6329 pixels, 95% CI 4299-9317). The SUS measure of overall usability demonstrated only minimal change in the novice group (Round 1: 69, high marginal; Round 2: 68, high marginal) and no change in the expert group (74; high marginal for both rounds)., Conclusions: This study found differences in novice and expert physicians' performance, demonstrating that physicians' proficiency increased with EHR experience. Our study may serve as a guideline to improve current EHR training programs. Future directions include identifying usability issues faced by physicians when using EHRs, through a more granular task analysis to recognize subtle usability issues that would otherwise be overlooked.