Integrated displays to improve chronic disease management in ambulatory care: A SMART on FHIR application informed by mixed-methods user testing

Abstract

Objective The study sought to evaluate a novel electronic health record (EHR) add-on application for chronic disease management that uses an integrated display to decrease user cognitive load, improve efficiency, and support clinical decision making. Materials and Methods We designed a chronic disease management application using the technology framework known as SMART on FHIR (Substitutable Medical Applications and Reusable Technologies on Fast Healthcare Interoperability Resources). We used mixed methods to obtain user feedback on a prototype to support ambulatory providers managing chronic obstructive pulmonary disease. Each participant managed 2 patient scenarios using the regular EHR with and without access to our prototype in block-randomized order. The primary outcome was the percentage of expert-recommended ideal care tasks completed. Timing, keyboard and mouse use, and participant surveys were also collected. User experiences were captured using a retrospective think-aloud interview analyzed by concept coding. Results With our prototype, the 13 participants completed more recommended care (81% vs 48%; P < .001) and recommended tasks per minute (0.8 vs 0.6; P = .03) over longer sessions (7.0 minutes vs 5.4 minutes; P = .006). Keystrokes per task were lower with the prototype (6 vs 18; P < .001). Qualitative themes elicited included the desire for reliable presentation of information which matches participants’ mental models of disease and for intuitive navigation in order to decrease cognitive load. Discussion Participants completed more recommended care by taking more time when using our prototype. Interviews identified a tension between using the inefficient but familiar EHR vs learning to use our novel prototype. Concept coding of user feedback generated actionable insights. Conclusions Mixed methods can support the design and evaluation of SMART on FHIR EHR add-on applications by enhancing understanding of the user experience.

Establishing a multidisciplinary initiative for interoperable electronic health record innovations at an academic medical center

“…Outcomes: An experimental simulation study of this tool for COPD management found that compared to the EHR alone, the app was associated with improved completion of recommended care (81% vs. 48%, P < 0.001), reduced time spent per task, and reduced user frustration. 59 A clinical trial is underway.…”

New Standards for Clinical Decision Support: A Survey of The State of Implementation

“…The most common study design was observational (n=8; 67%), with three studies (25%) reporting CDS needs evaluations. We identified only two studies with randomized components reporting on the use of any of the standards of interest (Curran et al [ 27 ] and Kawamoto et al [ 28 ]). Two (17%) articles reporting evaluations were in the design stage, seven (58%) were in the piloting stage, and a further three (25%) were deployed in real clinical settings.…”

“…For example, we searched only one database, our search strategy was not developed with assistance from an expert librarian, and the data analysis did not follow standard scoping review methods. As another limitation, the study was conducted over a short period in which we observed rapid development of the literature; the most recent article captured in the search was published in August, 2020 [ 27 ]. It is highly likely that new studies have been published that were not captured in our October 21, 2020 literature search at the time of writing.…”

Pattern of Use of Electronic Health Record (EHR) among the Chronically Ill: A Health Information National Trend Survey (HINTS) Analysis

“…Other strategies should include eHealth literacy programs that address patients’ concerns regarding safeguarding their protected health information. Additional technological improvements may include the use of integrated displays to decrease user cognitive load [ 49 , 50 , 51 ], integration of linked EHR records at the household level to facilitate delivery of services, and embedding of health literacy tools (e.g., embedded medical search engines, integrated AI voice chatbots for on-demand self-care advice) to facilitate meaningful patient engagement.…”