The effects of clinical information presentation on physicians’ and nurses’ decision-making in ICUs
Introduction
Advocates of electronic clinical information systems (CIS) that store and present patient and treatment related data assert that these systems can reduce medical error (Bates et al., 1998, Bates et al., 1999, Fraenkel et al., 2003, Institute of Medicine, 2001, Kohn et al., 2000), although this assertion has not been tested (Wears and Berg, 2005). Traditional paper-based CIS have evolved informally in response to changes in work practices and technology, but they have not been evaluated either. Given paper's widespread use, it has been reasonable to assume that traditional paper chart designs that include mixed graphs, tables and free-form text should be successful when implemented in an electronic format. However, reports and problems are emerging with electronic CIS information designs that have been copied from paper antecedents; some of these problems have the potential to create new types of errors (Ash et al., 2004, Koppel et al., 2005, Morris et al., 2005, Wears and Berg, 2005).
Berg et al. (1998) argue that many of the observed problems are grounded in assumptions about hospital work. Commercially available electronic CIS, for example, are typically implemented on computer terminals that were intended for use by office workers. Unlike office work, clinical decisions are collaborative activities that depend on team members being able to develop common understandings from information they can all see (Klein, 2001, Endsley et al., 2003). Small screen sizes make it difficult for team members to analyse large amounts of information. Paper charts are typically laid out on tables where separate pieces of information can be bought together given the issues at hand. Transferred to computer screens this capacity is lost as information is fragmented across multiple screens, making relationships between pieces of information difficult to see. Finally, only one person can use single input devices (eg a mouse) thus limiting collaborative interaction among people and with information.
To address these deficiencies new frameworks and approaches to information design have been developed based on the principle that electronic CIS should reflect the work of its main users, that is, nurses and physicians (Berg et al., 1998, Burns and Hajdukiewicz, 2004, Endsley et al., 2003, Gibson, 1979, Powsner and Tufte, 1994, Rasmussen et al., 1994, Vicente, 1999, Xiao, 2005, Zhang et al., 2002). Work domain analysis (WDA) is a framework for describing the relationships among elements (eg information) in a work environment in ways that usefully guide design (Rasmussen et al., 1994: Vicente, 1999). A WDA (reported in Miller, 2004, Miller and Sanderson, 2005) was completed for medical Intensive Care Units (ICUs) and used as a basis for information design within the ecological interface design approach (Burns and Hajdukiewicz, 2004). The research reported in this paper evaluates the effects of two CIS designs developed using the same WDA but displayed using different media. The overall purpose of the work was to determine whether there were differences in physicians' diagnostic agreement and nurses' ability to detect patient change when using traditional paper charts (TC) versus a WDA-based paper prototype (PP), and if so, whether these differences persisted when the PP was converted to an electronic prototype (EP). Conversion to an EP involved dividing information displayed in the PP. The EP's design rationale was the same as the PPs and information was divided using WDA principles. Two experiments were completed as described in the following sections.
Section snippets
Method
The two experiments were conducted in two major metropolitan tertiary teaching hospitals in different Australian cities in different years; both are recognised research centres. The ICUs were comparable in terms of patient demographics and severity of illness, bed numbers, types of technology and procedures undertaken. In summary, the first experiment (Brisbane, 2002) tested role-relevant aspects of ICU nurses' and physicians' performance when using traditional paper charts (TC) compared to a
Participant characteristics
Table 4 summarises the demographic characteristics of experiment 1 and 2 participants. The profiles for physicians represent a relatively homogenous sample.
The demographic and performance data were screened and tested for effects related to different gender proportions in experiment 1 and 2 nurses, for differences in nurses' years of experience and their hours of patient contact, for patient data set effects and for learning effects (the difference in performance between the first and second
Discussion
This study compared clinically relevant aspects of physicians' and nurses' performance when using traditional charts (TC) compared with two versions of a WDA-based prototype design (paper, PP, and electronic, EP). Findings suggest that as clinical information on paper charts is transferred to electronic media, traditional chart designs are unlikely to yield optimal physician/nurse performance. Specifically, results indicate that the presentation of information affects diagnostic agreement among
Acknowledgements
This research was jointly funded by the Australian Centre for Health Innovation and the Alfred Hospital, Intensive Care Unit. The authors gratefully acknowledge the participation of all medical and nursing staff at the Princess Alexandra Hospital, Brisbane, the Alfred Hospital, the Austin Hospital and the Epworth Hospitals in Melbourne, Australia. Prof. Penelope Sanderson provided advice to experiment 1 as the first author's PhD supervisor, and Dr. Matthew Weinger and Dr. Peter Buerhaus
Dr Anne Miller was awarded her PhD in 2004 from the University of Queensland, Australia where she also held the position of Coordinator of the Human Factors Online Post-graduate Program. She is currently a post-doctoral research fellow with the School of Nursing and the Center for Peri-operative Research in Quality at Vanderbilt University Medical Center, USA. Dr Miller has extensive consulting experience in IT enabled change management (PwC) and human–computer interaction (telecommunications).
References (25)
- et al.
Some unintended consequences of information technology in health care: the nature of patient care information system-related errors
J. Am. Med. Inform. Assoc.
(2004) - et al.
Considerations for sociotechnical design: experiences with an electronic patient record in a clinical context
Int. J. Med. Inform.
(1998) - et al.
Graphical summary of patient status
Lancet
(1994) - et al.
Improving communication in the ICU using daily goals
J. Crit. Care
(2003) Artifacts and collaborative work in healthcare: methodological, theoretical and technological implications of the tangible
J. Biomed. Inform.
(2005)- et al.
Effect of computerized physician order entry and a team intervention on prevention of serious medication errors
JAMA
(1998) - et al.
The impact of computerized physician order entry on medication error prevention
J. Am. Med. Inform. Assoc.
(1999) - et al.
Ecological Interface Design
(2004) - et al.
Designing for Situation Awareness: An Approach to User-Centered Design
(2003) - et al.
Quality benefits of an intensive care clinical information system
Crit. Care. Med.
(2003)
The Ecological Approach to Visual Perception
Signal Detection Theory and Psychophysics
Cited by (38)
Critical care information display approaches and design frameworks: A systematic review and meta-analysis
2019, Journal of Biomedical Informatics: XCitation Excerpt :Display designers frequently described an intention to organize the information in more clinically meaningful ways, for example, by human body systems, medical concepts, or provider tasks. In some of these, multiple variables are displayed as trend lines over time, with a common time axis that supports comparison of changes in patient state across different data and time points [47–49,51,53,55]. Configural or metaphor objects present multiple variables as objects (e.g., rectangles, stars, polygons) or as configural or metaphor graphics intended to make relationships between variables visually apparent (see Fig. 4).
Perception of Jordanian nurses regarding involvement in decision-making
2016, Applied Nursing ResearchModeling workflow to design machine translation applications for public health practice
2015, Journal of Biomedical InformaticsCitation Excerpt :We applied CWA to assist in determining the necessary functions and tasks of a translation system that would complement the work environment and the values and goals of the PH professionals involved in translation work. CWA has been used in multiple work settings including aviation, the petrochemical industry, vehicle safety, and health care environments [50–60]. Most applications of CWA have focused on interface design [60].
Evaluation of the effect of information integration in displays for ICU nurses on situation awareness and task completion time: A prospective randomized controlled study
2013, International Journal of Medical InformaticsCitation Excerpt :Doig et al. [15] found that nurses accuracy of blood gas incident identification increased significantly when using a visualization tool that consolidated multiple variables, significantly reducing response times. Miller et al. [16] found improved detection of patient changes when nurses used a display that grouped information around physiological functions. However, these displays only supported a limited range of tasks such as patient monitoring.
Patient Information Summarization in Clinical Settings: Scoping Review
2023, JMIR Medical Informatics
Dr Anne Miller was awarded her PhD in 2004 from the University of Queensland, Australia where she also held the position of Coordinator of the Human Factors Online Post-graduate Program. She is currently a post-doctoral research fellow with the School of Nursing and the Center for Peri-operative Research in Quality at Vanderbilt University Medical Center, USA. Dr Miller has extensive consulting experience in IT enabled change management (PwC) and human–computer interaction (telecommunications). She was formerly a Registered Nurse specialising in intensive care nursing.
Assoc. Prof, Carlos Scheinkestel is the Director of the Department of Intensive Care at the Alfred Hospital. He has been practising full time in intensive care since 1987. His roles have included: Chairman of the Victorian Branch and a member of the Board of Directors of the Australian and New Zealand Intensive Care Society and appointment by the Victorian Department of Human Services to the Ministerial Emergency and Critical Care Committee. He is a reviewer for national and international journals and has been a clinical examiner for the Colleges of Physicians, Anaesthetists and Emergency Medicine.
Ms Cathie Steele is the General Manager of the Australian Centre for Health Innovation at The Alfred Hospital in Melbourne. The Centre supports the development, testing and demonstration of systems and technologies that improve patient safety and quality of care. Cathie has had many years experience in health executive and management roles including physiotherapy, quality, patient safety, risk management and strategic planning. She has held the position of Clinical Associate Professor of Physiotherapy at Melbourne University, has worked in health consultancy, and is a surveyor with the Australian Council on Healthcare Standards.