multi-inclusion, universal client electronic health record ... · each group verdict is selected...

Multi-Inclusion, Universal Client Electronic Health Record: Assessement Volume (Version 2) Jihoon Kang, Christopher Goranson, PIIM, The New School Last Update: December 14, 2012

Multi-Inclusion, Universal Client Electronic Health Record: Assessment Volume Jihoon Kang, Christopher Goranson, PIIM, The New School Last Update: September 14, 2012

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I . INTRODUCTION This is the Assessment Volume for the Multi-Inclusion, Universal Client Electronic Health Record. The purpose of this document is to provide a full list of usability issues (violations) and recommendations from each usability evaluation on the Essentris DoD ED user interface and the usability evaluation methodology applied to each evaluation. This document also incorporates the feedback from the project stakeholder group. The Parsons Institute for Information Mapping (PIIM) team itemized all usability issues identified during evaluations with description of violation, occurrence of violation, severity, recommendation, and stakeholder group’s response which can be one of the following: “Low-hanging,” “High-hanging,” and “Decline.” The stakeholder group is expected to review each item carefully to determine whether the recommendation is feasible to apply onto the current Essentris DoD ED module. “Low-hanging” is marked when the recommendation can be applied to the current system. “High-hanging” is marked when the recommendation cannot be applied to the current system, but can be applied to the future version. “Decline” is marked when the recommendation is not accepted. The PIIM design will develop two graphical user interface (GUI) design sets based on the response from the stakeholder group. “Short-term GUI Recommendations and Enhancements” consists of the recommendations classified as “Low-hanging,” and this GUI set will be applied to the current Essentris DoD ED module immediately. “Long-term GUI Recommendations and Enhancements” consists of both “Low-hanging” and “High-hanging” recommendations, a design set for the future version (see Detailed GUI Design Volume for more information).


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II . METHODOLOGY Usability evaluation is a key element of this project. Before the team starts redesigning the existing user interface, the team must first identify usability problems and come up with solutions to improve the UI. PIIM has adopted Expert Review developed by National Institute of Standards and Technology (NIST) as the usability evaluation method. Expert Review, also known as heuristic evaluation, is tailored to evaluate electronic medical records system and composed of 12 usability principles. Below are the 12 principles paired with descriptions1: 1. Visibility of System Status The system should always keep the user informed about what is going on, through appropriate feedback within reasonable time. 2. Match Between System and the Real World The system should follow the user’s language, with words, phrases and concepts familiar to the user, rather than system-oriented terms. Follow real-world conventions, making information appear in a natural and logical order. 3. User Control and Freedom Users should be free to select and sequence tasks (when appropriate), rather than having the system do this for them. Users often choose system functions by mistake and will need a clearly marked “emergency exit” to leave the unwanted state without having to go through an extended dialogue. Users should make their own decisions (with clear information) regarding the costs of exiting current work. The system should support undo and redo. 4. Consistency and Standards Users should not have to wonder whether different words, situations or actions mean the same thing. Follow platform conventions. 5. Help Users Recognize, Diagnose, and Recover from Errors Error messages should be expressed in plain language (NO CODES). 6. Error Prevention Even better than good error messages is a careful design that prevents a problem from occurring in the first place. 7. Recognition Rather than Recall Make objects, actions and options visible. The user should not have to remember information from one part of the dialogue to another. Instructions for use of the system should be visible or easily retrievable whenever appropriate.

1 Walji M. and Zhang J. “Expert Review.” Creating Usable Electronic Health Records (EHRs): A User-Centered Design Best Practices Workshop. National Institute of Standards and Technology (NIST), Gaithersburg, MD. 22 May 2012. Walji M. and Zhang J. “Expert Review.” National Institute of Standards and Technology (NIST). 2012. PDF file. <http://www.nist.gov/itl/iad/upload/NIST-Expert-Review-final.pdf>


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8. Flexibility2 Accelerators-unseen by the novice user-may often speed up the interaction for the expert user such that the system can cater to both inexperienced and experienced users. Allow users to tailor frequent actions. Provide alternative means of access and operation for users who differ from the “average” user (e.g., physical or cognitive ability, culture, language, etc.). 9. Aesthetic and Minimalist Design Dialogues should not contain information that is irrelevant or rarely needed. Every extra unit of information in a dialogue competes with the relevant units of information and diminishes their relative visibility. 10. Help and Documentation Even though it is better if the system can be used without documentation, it may be necessary to provide help and documentation. Any such information should be easy to search, focused on the user’s task, list concrete steps to be carried out, and not be too large. 11. Pleasurable and Respectful Interaction with the User The user’s interactions with the system should enhance the quality of her or his work-life. The user should be treated with respect. The design should be aesthetically pleasing—with artistic as well as functional value. 12. Privacy The system should help the user to protect personal or private information belonging to the user or his/her patients. In order to determine the severity of the issue, the tester enters a rating level to each violation detected during the evaluation. There are 5 ratings:

Rating Severity 4 Catastrophic 3 Major 2 Moderate 1 Minor 0 No issue / Not applicable

PIIM is expecting to collaborate with the DoD ED CAG team to measure the severity on certain items requiring inputs from end-user and subject matter experts. Once the violation and severity are clearly identified per, each evaluator adds recommendations (e.g., change the font). PIIM follows the procedure guidelines created by NIST. NIST suggests that 2–5 evaluators independently detect issues and rate the severity. The report from each evaluation is later merged into a single master list. There are 5 evaluators of PIIM conducting Expert Review on Essentris DoD ED: 2 Originally this principle is “Flexibility and Mininalist Design.” However, we removed “Minimalst Design” in this category as it reappears in “Aesthetic and Minimalist Design.”


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Jihoon Kang, MFA — Co-Principal Investigator, Associate Director of PIIM Angela Laurio, RN — Medical Informatics Specialist Sayoko Yoshida, MFA — Senior Information Designer Prin Limphongpand, BFA — Information Designer Ann Yi, BFA — Information Designer


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III . USABILITY EVALUATION 3.1 DoD ED Tracking Board The PIIM team conducted the usability evaluation on DoD ED Essentris ED Tracking Board in the 4th quarter of the project (see Appendix A for details). PIIM delivered the formal usability report consisting of heuristic evaluation and design recommendations to the stakeholder group. In Quarter 5, PIIM collected comments and final verdicts from the following reviewers: Peter Park JF Lancelot Nicholas Allen Christopher Franklin Chris Strode Jason Turner Each group verdict is selected from the three categories of: Decline, Low-hanging Fruit (LHF), and High-hanging Fruit (HHF). As our goal is to deliver two separate design sets of LHF and HHF, the design team started building screens based on the final verdicts while applying the style guide generated in the 3rd quarter. Below is the final report containing PIIM’s report, reviewers’ comments, and final verdicts.


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ID

Place of Occurrence (Control, Display)

Usability Problem

Description

Usability Guidelines Violated

Severity

Score

Redesign Recommendation

Group Position (majority of reviewers agree)

Reviewer 1: Peter Park

Reviewer 2: JF Lancelot

Reviewer 3: Nicholas Allen

Reviewer 4: Christopher Franklin

Reviewer 5: Chris Strode

Reviewer 6: Jason Turner

Final Verdict (Low-‐hanging, High-‐hanging,

Decline)

1.01.09

Control Annotation icon is not necessary.

Aesthetic and Minimalist Design; Consistency and Standards; Recognition rather than Recall

1 Annotation icon as well as functionality can be removed if such feature is not utilized by the user.

Do not implement redesign recommendation

Remove annotation from the TB

Annotation should be supported as a matter of consistency throughout Essentris.

Although Parsons state that the ANNOTATION Icon is not necessary, it does provide a rather odd but cool functionality of adding the equivalent of Tool-‐tips to any box which is great for patient turnover, jotting down notes that actually get saved to the patients record (but not part of the DOD ED MEDICAL RECORD), and comes as a “Little Green Man” – ok, its really a green asterisk but I kinda like it. Granted, this could go away and my feelings not crushed, but it is useful. I’ve used it for many hundreds or more board turnovers.

High—Software change not something that can be changed via configuration. But doesn’t the end user annotate on some fields?

DECLINE

1.02.05

Display: Att (Attending Assigned) and Signed (Signing Provider)

Att (Attending Assigned) and Signed (Signing Provider) can be merged, if they share the same assignee.

Match between System and the Real World; Aesthetic and Minimalist Design

1 Merge these two columns if both columns always display the same name of the assigned physician twice to save space.

Do not implement redesign recommendations

Don't necessarily show the same info due to shift changes. Maybe sharing the signed column though for space.We should look at the WF at all the sites before making this call. Perhaps we can make this smaller? Ideally we need to train everyone to the same WF for the tools to work optimally for us all. Perhaps training?

Disagree – att and digning can be different based on the workflow – ED MD to confirm.

the signed column should be removed from the TB. Many of our staff physicians won't sign the chart for a day or two afterwards when they are going back through the charts. Having this column on the board just takes up real estate that could be better used for other things.

I have a lot of ideas for this. The system needs to be self aware so that one can click in the ATT or any of the sign-‐up boxes and it puts your initials in there. Having a full signature displayed is not needed of course but could be replaced with a different color of initials or something? Essentris cannot merge columns best of my knowledge.

High—Software change not something that can be changed via configuration.

DECLINE


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1.02.10

Display The columns are not organized effectively in terms of information architecture. The way columns have been clustered is not logical. For example, the columns can be clustered by the following groups: 1) patient profile (command interest, name, age, sex); 2) initial condition (triage category, chief complaint, fall risk); 3) assigned staff (nurse, resident, attending, name of signing provider); 4) location (bed, chart type, location, disposition plan); 5) tasks (pending orders, medication orders, nursing orders,

Match between System and the Real World; Consistency and Standards

2 Regroup and reorder columns based on their association. Recommended order: ChT, Bed, Triage Category (+ Fall Risk?), Command Interest (if necessary), Patient Name (+ Fall Risk?), Age, Gender, Chief Complaint, Fall Risk (if necessary), Length of Stay, Time Seen, Vitals, Orders and Results, Staff, Dis/Dispo, and Notes


May be possible, would need to review these recommendations and how the TB has grown in capability. These associations were made in the beginning, but perhaps a complete review would be helpful now.

I think the order of the columns is fine. If we didn’t like this years ago when we made it, we would have changed it. Since most monitors in DoD aren’t wide screen, the Orders chunk needs to stay where it is. Because we manually have to type in TS, that should stay put as well. It would be nice if we could “click” on our column with the capability that hopefully Essentris is going to with the weblinks placeable on Tracking Boards. We click, it adds time seen and our initials to the chart and sticks this chart in our in-‐box. So much could be done here and it is kinda lame to have to type all this goop in but I realize the limitations.

Low—This is something that can be done now

DECLINE


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untranscribed orders, lab orders, radiology orders, lab results, radiology results, unsigned orders, disposition orders); 6) vital signs (temperature, pulse, respirations, O2 sat %, systolic BP, diastolic BP); and 7) Notes.

1.02.14

Display: CC (Chief Complaint)

Need standards for CC (Chief Complaint) abbreviations.

Consistency and Standards; Error Prevention

2 Enable autofill or highlight unconventional terms with underline.


Can't do this unless we want to increase the data entry work for our people. Where would this fit in our workflow and how would this help?

Underline is already used to connote “unstored” in other Essentris screens. Agree with stakeholder comment.

Would not implement Low—Chief Complaint choicelist should be standardized

DECLINE

1.02.29

Display Staff names are inconsistently written; both upper case and lower case are used.

Consistency and Standards

1 Train staff to follow a convention in entering names. Use initials?


More difficult for the user. Is this worth the effort? What is the gain?

Work in progress. Low—choicelist needs to be modified

DECLINE

1.02.30

Display: ChT (Chart Type)

In the ChT column, Inpatient is highlighted in yellow.

Consistency and Standards; Aesthetic and Minimalist Design

1 Remove the highlight.


Tells you the patient has been admitted. It's an alert to help move the patient along. Until this happens the patient cannot go upstairs.

Keep the inpatient highlight! Sucks to chart on the wrong chart.

Low—Doable now

DECLINE


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1.02.40

Display Some ED workstations are connected to the internal network only. Those users cannot access to “Web Links” to obtain help.

Help and Documentation

1 Make offline help available.


I hadn't thought of this. We need to enable this.

The “stakeholder” here is probably the MTF, not CCI

I think it depends on the site. If nothing available, merely say Not Available perhaps or gray out the options (a common feature).

Skip "Medium"—This will require either embedding help documentation into Essentris or modifying network restrictions to files. Could be addressed with some network modifications to allow connectivity to documents within the Internal domain

DECLINE

1.02.42

Display Inconsistent right-‐mouse click actions are found. For example, right clicking Age takes the user to the top section of Note.

Pleasurable and Respectful Interaction with the User

2 Take the user to appropriate locations upon the right-‐mouse click.


Right-‐click takes you to the note where the information comes from so you cn change it.

I thought we already did a good job of right clicking and going to the right places?

Low—Configuration changes can fix this. Need to review the right click options and fix

DECLINE

1.02.50

Display When an item is not saved, it is indicated by a purple outline. This is too subtle.

Visibility of System Status

1 Apply a convention more visible for the unsaved items.


What is your recommendation? Flashing Cells? What can we do Jason? If different color?

I don’t agree. I like the purple.

I’m ok with as is. High—Software change not something that can be changed via configuration.

DECLINE

1.02.52

Display When an item is saved, there is no confirmation message.


1 Present a confirmation message when items are saved.


Good point. This needs to be fixed. Would seriously help with usability and user satisfaction.

Concur with stakeholder comment. In Ess, if it can’t save you get an error, else it quietly saves. This is consistent across all Ess apps. A message would be annoying.

Sorry Parsons – I despise confirmation messages. Screen and time and brain clutter.

Low—I think this is overkill

DECLINE


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A10 Display Indicate LoS through font weight (e.g., use regular for less than 3 hours, bold for longer than 3 hours).

N/A 0 Do not implement redesign recommendations

Need these to reflect what the community accepted standards are. Also the information should prompt clinicians to get patients moved out before they fail milestones/thresholds. LOS goals for admits, DCs, etc.

Font weight seems way to subtle to indicate LOS threshold.

Could but why? It is pretty obvious anyway. Would need to make the column wider then.

Low—This is configurable as of now.

DECLINE

A5 Display There is no indication of patients who have been seen and not seen by providers.

N/A 0 Indication for patients who have not been seen by providers.


Yes there is. When you've got the patient and assign your initials. That's supposed to mean you have seen the pt.

Can skip. Hence the green colors to the name section.

Low—Could be added to SB

DECLINE

A7 Display Combine Att and Signed


These are different pieces of data and Att can be entered from the TB

We need to reformat ALL of the signature stuff. As said above, EssED needs to fix this. The current solution is just lame. Click on icon in box, the system places your initials in the box, starts the time-‐stamp clock, places the chart in your inbox. Signature for another place.

Need more input DECLINE

A8 Display Combine Dis and Dispo


These are different data pieces. Don't know that they can be combined.

I think these have different meaning for the workflow. Need to validate with ED MD.

Perhaps an asterisk for Discharge WITHIN the Dispo column to show that one is ready?

Low DECLINE

A9 Display To protect patient's privacy, the default screen for individual station should only show the patient.


As a clinician I sometimes need to be able to scan the whole ED wherever I am. Understand about Privacy, BUT this is a clinical medicine workflow enabler.

So few people use bedside computing that I believe this is ok in current config.

Low DECLINE


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1.02.31

Display For temperature, color changes do not reflect the standard of care. CLARIFICATION: Often if a patient has a normal temp then it is checked less often than other VS, so the color change for an old measurement would have a different time requirement for temp than for BP, P, R, etc.

Match between System and the Real World

2 It should follow the standard of care. Also, use a visual cue to indicate abnormalities.

Do not implement redesign recommendations. Please see clarification in column C.

What do you mean? What is the standard of care?

The system can’t do heuristic thinking ie change vitals based on abnormalities AND age. I don’t know what the standard of care is for labeling temperature.

What are the standards for care?

DECLINE

1.02.36

Display Once the user sorts the list, he/she cannot return to the original sorting.

User Control and Freedom; Diagnose and Recover from Errors

1 Allow the user to return to the original state.

No change required Doesn't tapping on the A M&M do this? What is the logical way to enable users to return the TB to its native state?

Is there a misunderstanding?

I don’t agree. I have never seen this feature.

User can return to the original state by hitting the “A” button again.

Low—Only refreshing the screen will do re-‐sort to original

DECLINE


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1.02.07

Display: US (Unsigned Orders)

Unsigned Orders (US) reflects actions required by different users (MD and RN) with no way to differentiate who needs to take action.


1 Visual display should alert the user who needs to take action. If signee is always providers (MD/NP) then differentiation not necessary. Further investigation in progress. UPDATE: Per John Hughes 04 OCT 12 e-‐mail -‐ the only time US populates is when a non-‐provider enters an order that a provider must sign.

No change required, see update in column F

We may want to remove this as it doesn't work as intended right now

I agree. A column for each class of ED folk but I don’t know enough about EssED CPOE to get it.

Not sure if change is needed. More input needed to make decision

DECLINE

1.01.01

Control The four buttons (Rewind, Previous, Next, Fast Forward) do not show their definitions through the tooltips at hover.

Consistency and Standards; Flexibility

1 Add descriptions for each button through tooltips as it has been done for other buttons.

Implement redesign recommendation

Descriptions during hover would help novel users a lot.

Everything needs tooltips AND hot-‐keys so they are dragon configurable. Regarding this feature, does anyone know what this feature does?? I’ve never seen it used or used it myself.


HIGH


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1.01.02

Control The placement of the four navigation buttons (Beginning, Previous, Next, End), page number, and “Go To: page#” creates inconsistent gaps in-‐between items. For example, a gap between Annotation and the four buttons is big, while the gap between the four buttons and page number (“Page: 1 of 1”) is small. Furthermore, the gap between between the page number and “Go To: page#” is small.


1 Redistribute and relocate the items. As these buttons and fields (Beginning, Previous, Next, End, page number, and “Go To: page#”) are all related to page navigation, they can be clustered and placed on the left side in the row consistently. If the list fits in a single page and there is no need for pagination, remove all the buttons.


Good point. Once again, in the ED, this feature is not needed. Perhaps it can go away? Does anyone have so many pages of patients that are active in their ED that they use this? Even with ED-‐INCOM it doesn’t make sense. Otherwise, the spacing I’m ok with but a better choice is to do the Parsons recommendation of shoving it all to the left.


HIGH

1.01.03

Control When an invalid entry is submitted at “Go To: page#,” the system removes the number without presenting an error message.

Help Users Recognize, Diagnose and Recover from Errors

1 Display an error message when the user enters an inappropriate value to the field.


Good point Delete this functionality. Solves problem.


HIGH


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1.01.04

Control There are two Refresh buttons. One for Patient Control and the other for Tracking Board. Duplicate buttons can mislead the user.

Recognition rather than Recall; Consistency and Standards

1 There should be only 1 Refresh button. Refresh should be a global action (i.e., one row above) which refreshes the current screen.


Good point With a 30 second refresh rate, we can remove both buttons.


HIGH

1.01.05

Control Refresh button for Tracking Board can be removed if it is not necessary.

Aesthetic and Minimalist Design; Recognition rather than Recall; Consistency and Standards

1 Remove the button if the system automatically updates information.


It automatically refreshes. We should remove it.

Concur. Remove refresh buttons.


HIGH

1.01.06

Control There is no Redo button although there is an Undo button. Redo should be allowed after Undo is applied.

User Control and Freedom; Help Users Recognize, Diagnose and Recover from Errors

1 Add Redo button activated after the user applies Undo.


Remove refresh add redo.

I would be careful to clearly understand the underlying software logic taking place before allowing redo. This should be conditional depending on the use and not generically applied.

Redo would be nice. However, once saved, it cannot be undone. Currently the CTRL+Z works for UNDO PRIOR to saving but the CTRL+Y (windows standard) does NOT work for REDO. Having a button on the tracking board for this rarely used functionality doesn’t make sense. Would Delete this functionality.


HIGH

1.01.08

Control The icon for Choose Status Board is difficult to recognize.

Recognition rather than Recall

1 Redesign the icon.


Agree! Universal sentiment is that the icons suck.

We already have Status Boards on their own drop-‐down in the top-‐most header. Do we need a second ICON for such?


HIGH


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1.01.10

Control The user can read Chief Complaint by hovering over a CC cell. When annotation is added to the CC, it is represented by an asterisk (*) that appears in the right side of the cell. The user can view two different contents within the same cell, and this can be misleading.


2 When hovering, the user can see both chief complaint and annotation on the same text box.


Good point Good idea. However, the previous point said to delete it (I’d argue to keep it).


HIGH

1.02.06

Display When an item is selected, the font weight of the text changes from Regular to Black. Since the selected item (the row) is already indicated by the highlighted background, changing the font weight is not necessary. Another disadvantage of using Arial Black is that it


1 Keep the type treatment consistent regardless of the selection.

Implement redesign recommendations

I like this idea. I agree. I wonder if just warning text should be displayed in bold?

If Arial black requires more space then I would propose we go to another space-‐saving font.


HIGH


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requires more horizontal space.

1.02.11

Display: O (Orders)

The numbers in the O (orders) column represent the number of pending orders. The maximum number of viewable items when the user hovers over is 10. If there are 12 orders, the last 2 items will not be displayed.


2 Present all available pending orders when the user hovers over the cell.


Can engineering support an increase to 20?

Can it display more than 20 like you ask? Not a huge deal for us because we aren't using CPOD but inpatient orders are often more than 20...

Really? Max of 10? That needs to be fixed asap?!! Nothing like missing a critical order.

High—This is configurable as of now. It's defaulted to 10 but could be increased

HIGH

1.02.13

Display: O (Orders)

In the O column, the pop-‐up text field displaying details disappears after 7 seconds.


2 Let the pop up window stay on the screen. It should disappear only when the user is not hovering.


This would be great Concur. For all places where vital expandable information is present, this feature should be implemented.


HIGH

1.02.16

Display: UT (Untranscribed Orders)

The numbers on the UT (untranscribed orders) represent the number of orders to be entered into CHCS. It should present details (i.e., what the orders are) when the user hovers, but


2 Present all available untranscribed orders when the user hovers over the cell.


Integrating hover here would be great.

Needs details. Concur. High—Software change not something that can be changed via configuration.

HIGH


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it does not present details.

1.02.17

Display: Lab (Lab Orders)

The numbers in the Lab (lab orders) column represent the number of pending lab orders. It should present details (i.e., what the orders are) when the user hovers, but it does not present details.


2 Present all available lab orders when the user hovers over the cell.




HIGH

1.02.18

Display: Rad (Radiology Orders)

The numbers in the Rad (radiology orders) column represent the number of pending radiology orders. It should present details (i.e., what the orders are) when the user hovers, but it does not present details.


2 Present all available radiology orders when the user hovers over the cell.




HIGH


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1.02.19

Display: L (Lab Order Results)

L (lab order results) only displays the most recent lab order result although there may be more than one order result. Not having the complete list of all lab order results may not support the workflow of ED.


2 Present all available lab order results when the user hovers over the cell.


Can we show more than one result or have hover reveal the lab SS

It would be nice to hover over and see all the labs without going to the Lab screen. Also nice to see pending labs. If this cannot be done then at least show which labs were ordered AND resulted and which labs are ordered AND pending – this would be relatively simple to implement.


HIGH

1.02.20

Display: R (Radiology Results)

R (radiology results) only displays the most recent radiology result although there may be more than one radiology result. Not having the complete list of all radiology results may not support the workflow of ED.


2 Present all available radiology results when the user hovers.


We haven't really built out the rads piece

Concur. Concatenate the list?


HIGH


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1.02.22

Display The interface include many color codes, but there are no keys describing the meaning of each color.

Help and Documentation

2 Add a context-‐sensitive help to present the definition of color codes. A help button on the interface taking the user to the specific page (e.g., Cheat Sheet) within “Essentris Resource Center” can be helpful.


It's would be good. I agree 100% however I believe this should be a button or dropdown specifically available – resource center seems cumbersome for a quick reference on colors. If this is configurable to any extent, the quick reference should be generated from the configuration.

Color codes to a drop-‐down – can even use a current drop down such as “File” or “View”

"Medium"—Software change for quick help but we could create hotlink to specific help page in the RC

HIGH

1.02.23

Display When non-‐editable items are selected, they turn red. Since red carries multiple meanings on this UI, seeing another red item makes it confusing.


1 Change the color.


Yes. Good point. Would be nice to have a less alarming color

Concur Researching this one still

HIGH

1.02.24

Display When an item is selected, the system highlights the entire row where the item is located. When a row is highlighted, the color codes disappear as the


2 Keep the way the system is indicating the highlight, but leave the cells with color-‐coded background.


Yes. Concur That is kinda weird. I agree with Parsons.


HIGH


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highlight color (pale green) replaces the entire background of the row. The color codes should remain visible since the these carry meaningful information.

1.02.25

Display When a patient is selected, the color codes are replaced by the highlight, pale green color. However, marked F (Fall Risk) cells become letter X, and red vital signs become R.


1 Remove the letters and maintain the color code.


Yes. Better yet define the row behavior better as a set of robust rules.

That too is bizarre. Why did this happen?? Fix this.


HIGH

1.02.32

Display The text orientations of the column menu and the rest do not match. The column menus are centered whereas the rows below text is flush-‐left.


1 Keep the text orientation consistent (e.g., make vitals flash right) to show that they are related.


Good point we should change this

Agree but will this jack up the viewing of some columns? Someone would have to go through and reset them .


HIGH

1.02.33

Display: top row

Sorting: there is no indication for the active


1 Highlight or add indication to the column


Good point this would be helpful. Highlight the column?

Don’t know if this is worth doing.


HIGH


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column used for sorting.

where sorting option is applied.

1.02.34

Display: top row

Sorting: there is no indication of ascending or descending orders.


1 Add an arrowhead symbol to the top of the active column and indicate an ascending or descending order.


Good point this would be helpful

If this can be done easily then why not – if not then would not pursue.


HIGH

1.02.41

Display: bottom row

The four direction buttons on the bottom (next to the All, Triage, Core… tabs) do not seem functional.

Aesthetic and Minimalist Design

1 Remove these buttons if they are not functional.


They were not configured properly with the move. Fix Config. Need to put the step into the Config guide.

This is not functional on DHIMS so can skip.


HIGH

1.02.43

Display The response time takes too long after the right-‐mouse click.


1 Keep the response time immediate and consistent.


Agree. Keep right-‐click mouse function times the same and make them all quick!

"Medium"—Need to do some more testing to see if its configuration error

HIGH

1.02.45

Display: Loc (Location)

Drop-‐down menu for Location (Loc) is hidden.


1 Make the gateway to the drop-‐down menu more obvious (method TBD).


I don't understand LOC Drop down menu. It is odd and too thin. Need: Unbold. Entire colum of drop down present and visible instead of the same size as the originating column.


HIGH


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1.02.55

Display The system does not save the user's configuration.

User Control and Freedom

1 Enable user configuration.


CCI has been working on user preference for 4 years.

Certainly user configurations are common however these are limited and often isolated to the specific workstations being used and not carried over to other workstations except when treated as preferences or training such as Dragon.

YES!!!!!!!!!!! NEEEEEEEEED USERRRRR CONFIGURATIONNNNNNNN CAPABILITY!!!!


HIGH

A1 Display There is no visual cue of alerts when abnormal values are displayed (e.g., blood pressure out of the normal range).

N/A 0 Add visual cues to values out of the normal range. The normal range should be determined considering the patient's age (or other applicable biometric information).


Need to be able to act upon meta data. CCI has been unable to deliver this of the past 4.5 years and this is viewed as a major system weakness by the clinicians.

I agree but ranges may vary based on specific patient or even device such as manufacturer. This is pretty involved and should be evaluated carefully. Everywhere I go this seems to be brought up.

Yes, a chronic gripe. Fix the abnormal vitals with heuristics!


HIGH

A11 Display Indicate vitals through text color rather than background. As the vitals gets old, the color becomes lighter grey.

N/A 0 Implement redesign recommendations

This would be great. However CCI needs to change their tool to enable this logical GUI behavior.

Probably a better idea than background color – just to save the screen from Crayola nightmare.


HIGH


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A12 Display Assign distinct colors to groups of staff: 1) Nurses; 2) Clerks; 3) Providers (physicians, residents, and NP); 4) Technicians.

N/A 0 Implement redesign recommendations

How would this enable care and workflow. How would it look on the board. Which columns would b assigned to which people?

Sure, why not? Need more input HIGH

A2 Display: vital signs

Being able to see the trend of each vital sign value can be beneficial.

N/A 0 Hover mouse on each vital sign number to view a line graph for each measure.


Would be great. Hover over a patients vitals to see ALL of the prior vitals that patient had in a nice list format with time.


HIGH

1.02.39

Display Where the user can toggle between Tracking Board versions by clicking tabs located at the bottom of the screen. They are not prominent enough and intuitive.

User Control and Freedom

1 Make them more prominent.

Implement redesign recommendations, with possible modifications such as using tabs at the top or expanding user-‐configurable options.

Could we put the tabs to the top, ala Firefox Tabbed Browsing? That would be great.

We just need user-‐configurable and saveable TB screen preferences and discard the list of dozens of TB peset-‐settings.


HIGH


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1.02.02

Display The fonts used on the table are relatively extended letters (Arial, Arial Black). They take up horizontal space unnecessarily.


2 Use system fonts with either average width or condensed (narrow) face to save space. If the OS is Microsoft XP, Trebuchet MS might be a good substitute. This font includes Regular, Bold, Italic, and Bold Italic. If the Arial family is required, substitue Arial Black with Arial Bold.

Use smaller text where possible while maintaining readability

This is a good point. Use smaller text might help, but worried about people being able to read things. Perhaps just leave name larger

I would argue that the size of data itself dictates the more of the horizontal spacing allowed and that abbreviations or acronyms should be used as necessary if a column is commonly fewer characters.

I don’t see where this is.

High—Software change not something that can be changed via configuration. We can only change font size and not font type

HIGH

1.02.26

Display: Nur (Nurse Assigned)

Applying the green background to Nur is not necessary.


1 Remove green background.

Discuss possibility of color serving a function such as that described by CDR Park.

Wanted these to be red when nothing was charted and there was a patent in the bed.

I kinda like the colors for the backgrounds for the staff sign-‐up names.

Low—Doable now

LOW

1.02.27

Display: Res (Resident Assigned)

Applying the green background to Res is not necessary.






Low—Doable now

LOW

1.02.28

Display: Att (Attending Assigned)

Applying the green background to Att is not necessary.






Low—Doable now

LOW


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1.02.49

Display: Name

Showing patient's full name may violate HIPAA requirements.

Privacy 1 Few suggestions: 1) remove names entirely, 2) show the first letters, or 3) show initials.

Group prefers redesign of some kind however further discussion required. For HIPAA references please see: http://www.hipaa.com/2009/09/hipaa-‐protected-‐health-‐information-‐what-‐does-‐phi-‐include/ and http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html

It does not. Showing CC + Name = violation. One can be full and the other a code or abbreviation. I don't think we want to show r/o sexually transmitted disease. Name is preferable. Again, I'm good with either. However, only 1 can be shown completely. I vote we talk about this as a group make a call (again) and let this rest. Arguing about this is a no win situation as it will be personal preference driven... I want us to focus on the bigger struggles.

Disagee, CC is more important than name on an overall ED tracking board

Once again, we need to have a user customizable and savable capability to these TB’s. All this sizing and showing is a tad ridiculous.

Low—Configurable option

LOW

1.02.15

Display: NO (Nursing Orders)

The number in the NO (nursing orders) field is already included in the O column, which also has hover capability to view a complete list of orders.


1 Option 1: keep 'O' column with total number of unacknowledged orders. Option 2: Remove 'O' column and add visual indication for 'needs acknowledgement' in other orders fields.

Implement a hover feature It's analysis misses the workflow requirement. Integrating hover here would be great.

Unsure of what is said. I’m sure its important though.

Low—Clinicians need to decide which way works better

LOW


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1.01.07

Control Clear Data button is not necessary.

Consistency and Standards; Aesthetic and Minimalist Design; Match between System and Real World; User Control and Freedom

1 The user should be able to edit the content in a conventional way. For example, the user should be able to use Backspace or Delete key to clear the field.


Remove clear data button

The button was added as a result of a specific SCR (years ago). I think the issue is that the user will typically alter the entire cell (clear and start over) rather than do character by character editing of the cell. It seems helpful to have a single operation to do that. Do we know if anyone uses the clear-‐data button?

Clear data? That must be a functionality used in another environment. This could be deleted.

Low—Delete and backspace works to clear the field

LOW

1.02.01


There is not enough horizontal space to display the data. The CC (Chief Complaint) column is not wide enough to display its text-‐based information.


3 Remove unnecessary content (if applicable), merge columns (if applicable), and/or enhance type treatment (e.g., apply condensed type) to gain more horizontal space. (see ID 1.02.02 – 1.02.08)


We don't want it displayed. I'm good with either the Name or the CC. I think we should bring this up to the CAG and document it once more. Then I want to write up a spec for the TB to commit this to corporate memory. This is very much a style/personal WF issue.

I would like the CC column widened and displayed prominently on the board. You get better situational awareness of what's going on the dept. if you can see CC rather than name. Last initial of the last name and CC is what we have on the TB. On our white board we have the first three letters of the last name and the last 4 of SSN, plus CC.

Agreed. CC needs to be 20 characters long but I also realize there are a ton of SB’s made too. **Can the SB’s Column width be user configurable? We can resize columns but they don’t stick. This would be nice.

Low—We can remove columns from the SB to make the CC column wider. We can also change font size on the board.

LOW

1.02.03

Display: Sbp (Systolic blood pressure) and Dbp (Diastolic blood pressure)

Having separate columns of Sbp (Systolic blood pressure) and Dbp (Diastolic blood pressure) takes up space. The two columns can be


1 Instead of having separate columns to accommodate systolic BP (e.g., 142) and diastolic BP (e.g., 71), create a new merged column called “BP” and


Will this impact alerting?

I believe these should remain separated. One reason is for showing warnings when pressure falls outside an acceptable range. It is simplified for visually seeing the culprit when separated.

Agree with Parsons but I don’t think Essentris has this capability.

Low—We could create formula that combines the two items into one field. Still researching this otherwise Software change.

LOW


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combined to save space.

present the contents as “142/71.”

1.02.04

Display: A (Age) and S (Sex)

A (Age) and S (Sex) columns can be merged to save space.


1 Instead of having separate columns A (e.g., 84) and Sex (e.g., F), create a new merged column called “A & S” (or A&S or A/S) and present the contents as “84 F.”


Like it Also agree with Parsons but I don’t think Essentris has this capability.

Low—We could create formula that combines the two items into one field. Still researching this otherwise Software change.

LOW

1.02.08

Display There are many 0’s in orders columns, however they do not have any meaning. They make the screen look busy.


1 Remove 0's as they are not meaningful and blank cells can carry the same meaning.


Would like to remove the 0s

Jason is clever! Agree Low—We could change it so that zeros appear as same color as background

LOW

1.02.12

Display The response time for pop-‐ups to appear varies.


2 Make the response time immediate (no more than 2 seconds) and consistent.


This would be nice Concur Which pop-‐ups? LOW


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1.02.21

Display There are too many color codes used on the GUI. There are three sets of color codes representing: 1) Patient condition; 2) Actions; and 3) Time. The number of color codes can be reduced and visualized in different ways other than the background color of the cell.

Consistency and Standards; Recognition rather than Recall

2 Optimize the color code application. For example, each color should only have one meaning. E.g., red is only used to indicate action-‐required items and not a triage category.


Interesting please explain further. There is a lot of information on the screen how do we change the density logically not all alerting is the same.

Triage categories have their own colors by standard but a change in the color scheme is probably warranted.

Low—Configurable now but need decisions on best colors to use. Document the color choices and we will change SB

LOW

1.02.35

Display: Bed When the list is sorted by Bed, ED-‐10 comes after ED-‐1.


1 Use 2 digits to number beds: ED-‐01, 02, 03… so that ED-‐10 will come after ED-‐09.


Good point we should change this. Perhaps easiest to enforce single digits to be coded as 0x, e.g. 1 = 01, 2 = 02, etc. Jason, can we do this?

I like the naming convention of 01,02,etc. we also divide up our dept. into Blue and Green side so this is likely site specific changes that can be made locally.

I would consider a category 2

Agree but its relative importance is slim.

Low—You can modify the order of the beds on the status board. We change the order of the beds on tracking board. We can also relabel beds if needed.

LOW

1.02.37

Display: top row

The user should be able to see the full title of columns where the titles are abbreviated by hovering over each abbreviation (e.g., seeing “Chief Complaint” as hovering over “CC”).

Flexibility; Help and Documentation

2 Present the title fully spelled out on the tooltip when the user hovers over the abbreviated titles.


Good point this would be very helpful, perhaps even have a short (synoptic) explanation display as well.

Seems the stakeholder comment does not address tooltip desire.

I agree since I have heard this requested with other systems I have worked with however I don’t know that this is a category 2. I would think it depends on whether they can increase the size of the c column to see the full name using the mouse.

Agree Low—We could change the name of the Column header to the long name hence you will always see Title…..

LOW


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1.02.38

Display There is no indication that the user is viewing the Tracking Board screen.


2 Add a visible screen title on a designated location.


It's not that it's the TB that we need to see. It's the title of the TB we need to display since there are multiple. Where would we put this? Logically to the top left. Other data to top right, e.g. Date/Time.

Not clear to me what this meant.

Huh? Ok Low—there is a title bar showing the name of the tracking board

LOW

1.02.44

Display Some columns such as LoS, ChT, Rx, NO, UTO, Lab, Rad, L, R, US, Signed, Dis do not allow the right-‐mouse click.

User Control and Freedom; Consistency and Standards; Pleasurable and Respectful Interaction with User

2 Enable right click for all columns, and take the user to appropriate locations.


We need to study these and assign the correct right clicks.

Agree Low—Configuration changes can fix this. Need to review the right click options and fix

LOW

1.02.46


The user can select multiple locations from the Loc drop-‐down menu.

Error Prevention; Match between System and Real World

1 Allow the user to select only 1 location at a time.


Good point LOC Drop down menu. It is odd and too thin. Need: Unbold. Entire colum of drop down present and visible instead of the same size as the originating column.


LOW

1.02.47


Options in the drop-‐down menu are not organized in a logical order.


1 Reorganize the list in more logical order, such as alphabetical order.


It should be organized and is in order of freq of use... Alphabetical is not as efficient.

Sort order could be by frequency of use as an alternative to alphabetical.

Drop downs can also be grouped and separated into the groups by offering a line separator ‘-‐-‐-‐-‐-‐-‐-‐‘. Order should be consistent for navigation.

LOC Drop down menu. It is odd and too thin. Need: Unbold. Entire colum of drop down present and visible instead of the same size as the originating column.


LOW

1.02.48


The width of drop-‐down menu is so narrow that the user has to scroll horizontally.


1 Expand the width of the drop-‐down menu so that the user can read the options without scrolling horizontall


Good point this would help.

Not sure we can alter this AND retain column width without sw change? Should this be “high”?

LOC Drop down menu. It is odd and too thin. Need: Unbold. Entire colum of drop down present and visible instead of the same size as the originating column.


LOW


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y. 1.02.51

Display There is no shortcut for Save.

Flexibility 1 Enable a keyboard shortcut, such as Ctrl + S.


Good point. This needs to be fixed. Would seriously help with usability and user satisfaction.

Is there a misunderstanding?

DHIM’s doesn’t work properly for this functionality otherwise, this wouldn’t have come up on Parsons Radar.

Low—Ctrl + S works

LOW

1.02.53

Display: L (Lab Results) and Lab (Lab Orders)

There is no indication of the difference between L and Lab.


2 Make a single convention to represent lab. Another solution is to cluster columns by category, orders and results.


LbO and LbR? I think the system is ok as is. I do agree with Parsons however.

Low—Could change the configuration labels

LOW

1.02.54

Display: R (Radiology Results) and Rad (Radiology Orders)

There is no indication of the difference between R and Rad.


2 Make a single convention to represent radiology. Another solution is to cluster columns by category, orders and results.


RdO and RdR? Same as above Low—Could change the configuration labels

LOW

A3 Display There is no weight in the current interface.

N/A 0 Add Weight to the patient information row.


Good point. Can skip weight Low—Could be added to SB

LOW

A4 Display There is no pain assessment column in the current interface.

N/A 0 Add Pain Assessment column to the vital sign group.


We don't like pain assessments, but this might help us improve our patient satisfaction around pain treatment.

This is actually a pretty good idea. Can pain be put here on the TB and saved to the Flow Sheet and then remove pain from the DOD ED MEDICAL RECORD? Stupid JCAHO.

Low—Could be added to SB

LOW


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A6 Display Remove C, F, ChT, US

N/A 0 Implement redesign recommendations with modifications.

Will have to review these individually. I agree with US, but not necessarily the others.

I think we need to keep this.

Low LOW

1.02.09

Display In the ED, beds are grouped by pods, but the current UI does not group the beds by pods.


1 Add visual cues (e.g., thicker outlines) grouping beds by pod. Also consider displaying only beds that are relevant to the user when the tracking board is viewed at an individual station.

Implement redesign recommendations, with possible modification such as adding a pod "prefix."

This is a site configuration. We need to this into the implementation and and ANNUAL REVIEW guide.

I’m not sure the stakeholder comment truly addresses the POD issue. Perhaps renaming the beds to include the pod prefix would help?

Jason can do this. DHIMS doesn’t represent this well.

Low—You can modify the order of the beds on the status board. The config doesn't allow certain beds to be viewed based on location

LOW

***** Additional Recommendations *****


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Other Reviewer Comments (1)

Further Notation: (1) I only ever merge content when it is not sued for search (i.e. order by) selection. (2) Red is commonly an ‘Off limits’ color. One doctor told me that when he sees red it means either possible patient safety risk or requires attention. I believe this is a priority for standardizing. I believe all instances should be considered category 2/3. (3) I agree green is generally unnecessary unless it is something such as ‘available’ or ‘ready.’ (4) When a system is offline or disconnected from the network – or does not have external connectivity, it would be important for a doctor to get a visual indicator. (5) We should enforce mouse ‘hour glass’ when possible.

(1) Everything on the TB possible needs a tool-‐tip and a short-‐cut key assigned so that they are Dragon or As-‐U-‐Type configurable. (2) There is a lot of duplicity on the screen. Extra refresh buttons, extra status board buttons. Can be deleted. (3) Can the SB’s Column width be user configurable? We can resize columns but they don’t stick. This would be nice. (4) More user presets needed re: FONTS. Too much wasted space on large fonts.


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Other Reviewer Comments (2)

W81XWH-‐11-‐2-‐0183_PIIM_DetailedGUIVolume-‐01.pdf, page 13: I believe the Vitals Plot row in blue should have text in block not white. These are important descriptors. In fact, I would probably put a very thin black box around each graphic symbols to highlight it is a symbol. This is a common way of illustrating a symbol legend.


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Appendix A:

DoD ED Tracking Board Heuristic Evaluation Report

Heuristic Evaluation Report Subject: Essentris ED Tracking Board Evaluator: Jihoon Kang, Angela Laurio, Sayoko Yoshida, Ann Yi, Prin Limphongpand Parsons Institute for Information Mapping, The New School

Version: 1 Last Update: 21 September 2012 ID Place of

Occurrence (Control, Display)

Usability Problem Description Usability Guidelines Violated

Severity Score

Redesign Recommendation

Stakeholder Review (Low-hanging, High-hanging, Decline)

1.01.01

Control The four buttons (Rewind, Previous, Next, Fast Forward) do not show their definitions through the tooltips at hover.

Consistency and Standards; Flexibility

1 Add descriptions for each button through tooltips as it has been done for other buttons.


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1.01.02

Control The placement of the four navigation buttons (Beginning, Previous, Next, End), page number, and “Go To: page#” creates inconsistent gaps in-between items. For example, a gap between Annotation and the four buttons is big, while the gap between the four buttons and page number (“Page: 1 of 1”) is small. Furthermore, the gap between between the page number and “Go To: page#” is small.


1 Redistribute and relocate the items. As these buttons and fields (Beginning, Previous, Next, End, page number, and “Go To: page#” are all related to page navigation, they can be clustered and placed on the left side in the row consistently. If the list fits in a single page and there is no need for pagination, remove all the buttons.

1.01.03

Control When an invalid entry is submitted at “Go To: page#,” the system removes the number without presenting an error message.

Help Users Recognize; Diagnose and Recover from Errors

1 Display an error message when the user makes an inappropriate value to the field.

1.01.04

Control There are two Refresh buttons. One for Patient Control and the other for Tracking Board. Duplicated buttons can mislead the user.

Recognition rather than Recall; Consistency and Standard

1 There should be only 1 Refresh button. Refresh should be a global action (i.e., one row above) which refreshes the current screen.

1.01.05

Control Refresh button for Tracking Board can be removed if it is not necessary.

Aesthetic and Minimalist Design; Recognition rather than Recall; Consistency and Standard

1 Remove the button if the system automatically updates information.


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1.01.06

Control There is no Redo button although there is the Undo button. Redo should be allowed after Undo is applied.

User Control and Freedom; Help Users Recognize; Diagnose and Recover from Errors

1 Add Redo button activated after the user applies Undo.

1.01.07

Control Clear Data button is not necessary.

Consistency and Standard; Aesthetic and Minimalist Design; Match between System and Real World; User Control and Freedom

1 The user should be able to edit the content in a conventional way. For example, the user should be able to use Backspace or Delete key to clear the field.

1.01.08

Control The icon for Choose Status Board is difficult to recognize.

Recognition rather than Recall

1 Redesign the icon.

1.01.09

Control Annotation icon is not necessary.

Aesthetic and Minimalist Design; Consistency and Standards; Recognition rather than Recall

1 Annotation icon as well as functionality can be removed if such feature is not utilized by the user.

1.01.10

Control The user can read Chief Complaint by hovering over a CC cell. When annotation is added to the CC, it is represented by an asterisk (*) that appears in the right side of the cell. The user can view two different contents within the same cell, and this can be misleading.

Consistency and Standard 2 When hover, the user can see both chief complaint and annotation on the same text box.


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1.02.01

Display: CC (Chief Complaints)

There is not enough horizontal space to display the data. The CC (Chief Complaints) column is not wide enough to display its text-based information.

Consistency and Standards 3 Remove unnecessary content (if applicable), merge columns (if applicable), and/or enhance type treatment (e.g., apply condensed type) to gain more horizontal space. (see ID 1.02.02 – 1.02.08)

1.02.02

Display The fonts used on the table are relatively extended letters (Arial, Arial Black). They take up horizontal space unnecessarily.

Consistency and Standards 2 Use system fonts with either average width or condensed (narrow) face to save space. If the OS is Microsoft XP, Trebuchet MS might be a good substitute. This font includes Regular, Bold, Italic, and Bold Italic. If the Arial family is required, substitue Arial Black with Arial Bold.

1.02.03

Display: Sbp (Systolic blood pressure) and Dbp (Diastolic blood pressure)

Having separate columns of Sbp (Systolic blood pressure) and Dbp (Diastolic blood pressure) takes up space. The two columns can be combined to save space.


1 Instead of having separate columns to accommodate systolic BP (e.g., 142) and diastolic BP (e.g., 71), create a new merged column called “BP” and present the contents as “142/71.”


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1.02.04

Display: A (Age) and S (Sex)

A (Age) and S (Sex) columns can be merged to save space.


1 Instead of having separate columns A (e.g., 84) and Sex (e.g., F), create a new merged column called “A & S” (or A&S or A/S) and present the contents as “84 F.”

1.02.05

Display: Att (Attending Assigned) and Signed (Signing Provider)

Att (Attending Assigned) and Signed (Signing Provider) can be merged, if they share the same assignee.


1 Merge these two columns if both columns always display the same name of the assigned physician twice to save space.

1.02.06

Display When an item is selected, the font weight of the text changes from Regular to Black. Since the selected item (the row) is already indicated by the highlighted background, changing the font weight is not necessary. Another disadvantage of using Arial Black is that it requires more horizontal space.


1 Keep the type treatment consistent regardless of the selection.

1.02.07

Display: US (Unsigned Orders)

Unsigned Orders (US) is not a part of Tracking Board workflow and should be removed.


1 Remove the column.

1.02.08

Display There are many 0’s in orders. However they do not carry any meanings. They make the screen look busy.


1 Remove 0's as they are not meaningful and blank cells can carry the same meaning.


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1.02.09

Display At the ER, beds are grouped by pods, but the current UI does not group the beds by pods.


1 Add visual cues (e.g., thicker outlines) grouping beds by pod. Also consider displaying only beds that are relevant to the user when the tracking board is viewed at an individual station.


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1.02.10

Display The columns are not organized effectively in terms of information architecture. The way columns have been clustered is not logical. For example, the columns can be clustered by the following groups: 1) patient profile (command interest, name, age, sex); 2) initial condition (triage category, chief complaint, fall risk); 3) assigned staffs (nurse assigned, resident assigned, attending assigned, name of signing provider); 4) location (bed, chart type, location, disposition plan); 5) tasks (pending orders, medication orders, nursing orders, untranscribed orders, lab orders, radiology orders, lab results, radiology results, unsigned orders, disposition orders); 6) vital signs (temperature, pulse, respirations, O2 sat %, systolic BP, diastolic BP); and 7) Notes.

Match between System and the Real World; Consistency and Standards

2 Regroup and reorder columns based on their association. Recommended order: ChT, Bed, Triage Category (+ Fall Risk?), Command Risk (if necessary), Patient Name (+ Fall Risk?), Age, Gender, Chief Complaint, Fall Risk (if necessary), Length of Stay, Time Seen, Vitals, Orders and Results, Staffs, Dis/Dispo, and Notes


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1.02.11

Display: O (Orders)

The numbers in the O (orders) column represent the number of pending orders. The maximum number of viewable items when the user hovers over is 10. If there are 12 orders, the last 2 items will not be displayed.


2 Present all available pending orders when the user hovers over the cell.

1.02.12

Display The response time of pop-ups to appear varies.


2 Make the response time immediate (no more than 2 seconds) and consistent.

1.02.13

Display: O (Orders)

In the O column, the pop-up text field displaying details disappears after 7 seconds.


2 Let the pop up window stay in the screen. It should disappear only when not hovered.

1.02.14


Need standards for CC (Chief Complaint) abbreviations.

Consistency and Standards; Error Prevention

2 Enable autofill or highlight unconventional terms with underline.

1.02.15

Display: RN (Nursing Orders)

The numbers on the RN (nursing orders) represent the number of pending orders. It should present details (i.e., what the orders are) when user hover, but it does not present details.


2 Present all available nursing orders when the user hovers over the cell.

1.02.16

Display: UT (Untranscribed Orders)

The numbers on the UT (untranscribed orders) represent the number of pending orders. It should present details (i.e., what the orders are) when user hover, but it does not present details.


2 Present all available untranscribed orders when the user hovers over the cell.


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1.02.17

Display: Lab (Lab Orders)

The numbers on the Lab (lab orders) represent the number of pending orders. It should present details (i.e., what the orders are) when user hover, but it does not present details.


2 Present all available lab orders when the user hovers over the cell.

1.02.18

Display: Rad (Radiology Orders)

The numbers on the Rad (radiology orders) represent the number of pending orders. It should present details (i.e., what the orders are) when user hover, but it does not present details.


2 Present all available radiology orders when the user hovers over the cell.

1.02.19

Display: L (Lab Order Results)

L (lab order results) only displays the most recent lab order result although there may be more than one order result. Not having the complete list of all lab order results may not support the workflow of ED.


2 Present all available lab order results when the user hovers over the cell.

1.02.20

Display: R (Radiology Results)

R (radiology results) only displays the most recent radiology result although there may be more than one radiology result. Not having the complete list of all radiology results may not support the workflow of ED.


2 Present all available radiology results when the user hovers.


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1.02.21

Display There are too many color codes used on the GUI. There are three sets of color codes representing: 1) Patient condition; 2) Actions; and 3) Time. The number of color codes can be reduced and visualized in different ways other than the background color of the cell.

Consistency and Standards; Recognition rather than Recall

2 Optimize the color code application. For example, each color should only represent one meaning. Red is only used to indicate action-required items, not the triage categories.

1.02.22

Display The interface include many color codes, but there are no keys describing the meaning of each color.

Help and Documentation 2 Add a context-sensitive help to present the definition of color codes. A help button on the interface taking the user to the specific page (e.g., Cheat Sheet) within “Essentris Resource Center” can be helpful.

1.02.23

Display When non-editable items are selected, they turn red. Since red carries multiple meanings on this UI, seeing another red item makes it confusing.


1 Change the color.

1.02.24

Display When an item is selected, the system highlights the entire row where the item is located. When a row is highlighted, the color codes disappear as the highlight color (pale green) replaces the entire background of the row. The color codes should remain visible since the these carry meaningful information.

Consistency and Standards 2 Keep the way the system is indicating the highlight, but leave the cells with color-coded background.


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1.02.25

Display When a patient is selected, the color codes are replaced by the highlight, pale green color. However, marked F (Fall Risk) cells become letter X, and red vital signs become R.

Consistency and Standards 1 Remove the letters and maintain the color code.

1.02.26

Display: Nur (Nurse Assigned)

Applying the green background to Nur is not necessary.



1.02.27

Display: Res (Resident Assigned)

Applying the green background to Res is not necessary.



1.02.28

Display: Att (Attending Assigned)

Applying the green background to Att is not necessary.



1.02.29

Display Staff names are inconsistently written; both upper case and lower case are used.

Consistency and Standards 1 Train staff to follow the convention in entering names. Use initials?

1.02.30

Display: ChT (Chart Type)

In the ChT column, Inpatient is highlighted in yellow.


1 Remove the highlight.

1.02.31

Display For temperature, color changes do not reflect the standard of care.


2 It should follow the standard of care. Also, use a visual cue to indicate abnormalities.

1.02.32

Display The text orientations of the column menu and the rest do not match. The column menus are centered whereas the rows below text is flush-left.

Consistency and Standards 1 Keep the text orientation consistent (e.g., make vitals flash right) to show that they are related.


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1.02.33

Display: top row Sorting: there is no indication for the active column used for sorting.

Visibility of System Status 1 Highlight or add indication to the column where sorting option is applied.

1.02.34

Display: top row Sorting: there is no indication of ascending or descending orders.

Visibility of System Status 1 Add an arrowhead symbol to the top of the active column and indicate an ascending or descending order.

1.02.35

Display: Bed When the list is sorted by Bed, ED-10 comes below ED-1.

Consistency and Standards 1 Add 2 digits and name the beds ED-01, 02, 03… so that ED-10 will come after ED-9.

1.02.36

Display Once the user sorts the list, he/she cannot return to the original sorting.

User Control and Freedom; Diagnose and Recover from Errors

1 Allow the user to return to the original state.

1.02.37

Display: top row The user should be able to see the full title of columns where the titles are abbreviated by hovering over each abbreviation (e.g., seeing “Chief Complaint” as hovering over “CC”).

Flexibility; Help and Documentation

2 Present the title fully spelled out on the tooltip when the user hovers over the abbreviated titles.

1.02.38

Display There is no indication that the user is viewing the Tracking Board screen.

Visibility of System Status 2 Add a visible screen title on a designated location.

1.02.39

Display Where the user can toggle between Tracking Board versions by clicking tabs located in the bottom of the screen. They are not prominent enough and intuitive.

User Control and Freedom 1 Make them look more prominent.


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1.02.40

Display Some ED workstations are connected to the internal network only. Those users cannot have access to “Web Links” where they can obtain help.

Help and Documentation 1 Make offline help available.

1.02.41

Display: bottom row

The four direction buttons on the bottom (next to the All, Triage, Core… tabs) do not seem functional.


1 Remove these buttons if they are not functional.

1.02.42

Display Inconsistent right-mouse click actions are found. For example, right clicking Age takes the user to the top section of Note.


2 Take the user to appropriate locations upon the right-mouse click.

1.02.43

Display The response time takes too long after the right-mouse click.


1 Keep the response time immediate and consistent.

1.02.44

Display Some columns such as LoS, ChT, Rx, NO, Ulto, Lab, Rad, L, R, US, Signed, Dis do not allow the right-mouse click.

User Control and Freedom; Consistency and Standards; Pleasurable and Respectful Interaction with User

2 Enable right click for all columns, and take the user to appropriate locations.

1.02.45


Drop-down menu for Location (Loc) is hidden.


1 Make the gateway to the drop-down menu more obvious (method TBD).

1.02.46


The user can select multiple locations from the Loc drop-down menu.

Error Prevention; Match between System and Real World

1 Allow the user to select only 1 location at a time.

1.02.47


Options in the drop-down menu is not organized in a logical order.

Consistency and Standards 1 Reorganize the list in more logical order, such as an alphabetical order.


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Additional Recommendations

1.02.48


The width of drop-down menu is so narrow that the user has to scroll horizontally.


1 Expand the width of the drop-down menu so that the user can read the options without scrolling horizontally.

1.02.49

Display: Name Showing patient's full name may violate HIPAA requirements.

Privacy 1 Few suggestions: 1) remove names entirely, 2) show the first letters, or 3) show initials.

1.02.50

Display When an item is not saved, it is indicated by a purple outline. This is too subtle.

Visibility of System Status 1 Apply a convention more visible for the unsaved items.

1.02.51

Display There is no shortcut for Save. Flexibility 1 Enable a keyboard shortcut, such as Ctrl + S.

1.02.52

Display When an item is saved, there is no confirmation message.

Visibility of System Status 1 Present a confirmation message when items are saved.

1.02.53

Display: L (Lab Results) and Lab (Lab Orders)

There is no indication of the difference between L and Lab.


2 Make a single convention to represent lab. Another solution is to cluster columns by category, orders and results.

1.02.54

Display: R (Radiology Results) and Rad (Radiology Orders)

There is no indication of the difference between R and Rad.


2 Make a single convention to represent radiology. Another solution is to cluster columns by category, orders and results.

1.02.55

Display The system does not save the user's configuration.

User Control and Freedom 1 Enable user configuration.


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A1 Display There is no visual cue of alerts

when there are abnormal values are displayed (e.g., blood pressure out of the normal range).

N/A 0 Add visual cues to values out of the normal range. The normal range should be determined considering the patient's age (or other applicable biometric information).

A2 Display: vital signs Being able to see the trend of each vital sign value can be beneficial.

N/A 0 Hover mouse on each vital sign number to view a line graph for each measure.

A3 Display There is no weight in the current interface.

N/A 0 Add Weight to the patient information row.

A4 Display There is no pain assessment column in the current interface.

N/A 0 Add Pain Assessment column to the vital sign group.

A5 Display There is no indication of patients who have seen and not seen by providers.

N/A 0 Indication for patients who have not been seen by providers.

A6 Display Remove C, F, ChT, US N/A 0 A7 Display Combine Att and Signed N/A 0 A8 Display Combine Dis and Dispo N/A 0 A9 Display To protect patient's privacy, the

default screen for individual station should only show the patient.

N/A 0

A10 Display Indicate LoS through font weight (e.g., use regular for less than 3 hours, bold for longer than 3 hours).

N/A 0


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A11 Display Indicate vitals through text color rather than background. As the vitals gets old, the color become lighter grey.

N/A 0

A12 Display Assign distinct colors to groups of staff: 1) Nurse; 2) Clerk; 3) Providers (physicians, residents, and NP); 4) Technicians.

N/A 0

multi-inclusion, universal client electronic health record ... · each group verdict is selected...

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