JMIR Publications

ABSTRACT

Background:

The potential of the electronic health record (EHR) and clinical decision support (CDS) to improve the practice of medicine have been significantly tempered by poor design and the resulting burden they place on health care providers. CDS is rarely tested in the real clinical environment. As a result many tools are hard to use, placing strain on providers and resulting in low adoption rates. The existing CDS usability literature relies primarily on expert opinion and provider feedback via survey.

Objective:

This is the first study to evaluate CDS usability and the provider-computer-patient interaction with complex CDS in the real clinical environment. The objective of this study was to further understand barriers and facilitators of meaningful CDS usage within a real clinical context.

Methods:

This qualitative observational study was conducted with three primary care providers during a total of six patient care sessions. In patients with the chief complaint of sore throat a CDS tool built with the Centor Score was used to stratify the risk of group A strep pharyngitis. In patients with a chief complaint of cough or upper respiratory infection a CDS tool built with the Heckerling Rule was used to stratify the risk of pneumonia. During usability testing all human-computer interactions, including audio and continuous screen capture, were recorded using Camtasia® software. Participants’ comments and interactions with the tool during patient care sessions and participant comments during a post-session brief interview were placed into coding categories and analyzed for generalizable themes

Results:

In the 6 encounters observed, primary care providers toggled between addressing either the computer or the patient during the visit. Minimal time was spent listening to the patient without engaging the EHR. Participants almost always used the CDS tool with the patient, asking questions to populate the calculator and discussing the results of the risk assessment; they reported the ability to do this as the major benefit of the tool. All primary care providers were interrupted during their use of the CDS tool by the need to refer to other sections of the chart. In half of the visits, patient’s clinical symptoms challenged the applicability of the tool to calculate the risk of bacterial infection. Primary care providers rarely used the incorporated incentives for CDS usage, including progress notes and patient instructions/documentation

Conclusions:

Live usability testing of these CDS tools generated insights about their role in the patient-provider interaction. CDS may contribute to the interaction by being simultaneously viewed by provider and patient. CDS can improve usability and lessen the strain it places on providers by being short, flexible and customizable to unique provider workflow. A useful component of CDS is being as widely applicable as possible and ensuring that its functions represent the fastest way to perform a particular task. Clinical Trial: Live usability testing of these CDS tools generated insights about their role in the patient-provider interaction. CDS may contribute to the interaction by being simultaneously viewed by provider and patient. CDS can improve usability and lessen the strain it places on providers by being short, flexible and customizable to unique provider workflow. A useful component of CDS is being as widely applicable as possible and ensuring that its functions represent the fastest way to perform a particular task.