Nicole B. Arbuckle

Redesign of a computerized clinical reminder for colorectal cancer screening: a human-computer interaction evaluation

BackgroundBased on barriers to the use of computerized clinical decision support (CDS) learned in an earlier field study, we prototyped design enhancements to the Veterans Health Administrations (VHAs) colorectal cancer (CRC) screening clinical reminder to compare against the VHAs current CRC reminder.MethodsIn a controlled simulation experiment, 12 primary care providers (PCPs) used prototypes of the current and redesigned CRC screening reminder in a within-subject comparison. Quantitative measurements were based on a usability survey, workload assessment instrument, and workflow integration survey. We also collected qualitative data on both designs.ResultsDesign enhancements to the VHAs existing CRC screening clinical reminder positively impacted aspects of usability and workflow integration but not workload. The qualitative analysis revealed broad support across participants for the design enhancements with specific suggestions for improving the reminder further.ConclusionsThis study demonstrates the value of a human-computer interaction evaluation in informing the redesign of information tools to foster uptake, integration into workflow, and use in clinical practice.

Sources of variation in primary care clinical workflow: implications for the design of cognitive support.

This article identifies sources of variation in clinical workflow and implications for the design and implementation of electronic clinical decision support. Sources of variation in workflow were identified via rapid ethnographic observation, focus groups, and interviews across a total of eight medical centers in both the Veterans Health Administration and academic medical centers nationally regarded as leaders in developing and using clinical decision support. Data were reviewed for types of variability within the social and technical subsystems and the external environment as described in the sociotechnical systems theory. Two researchers independently identified examples of variation and their sources, and then met with each other to discuss them until consensus was reached. Sources of variation were categorized as environmental (clinic staffing and clinic pace), social (perception of health information technology and real-time use with patients), or technical (computer access and information access). Examples of sources of variation within each of the categories are described and discussed in terms of impact on clinical workflow. As technologies are implemented, barriers to use become visible over time as users struggle to adapt workflow and work practices to accommodate new technologies. Each source of variability identified has implications for the effective design and implementation of useful health information technology. Accommodating moderate variability in workflow is anticipated to avoid brittle and inflexible workflow designs, while also avoiding unnecessary complexity for implementers and users.

Paper Persistence and Computer-based Workarounds with the Electronic Health Record in Primary Care

With the United States national goal and incentive program to transition from paper to electronic health records (EHRs), healthcare organizations are increasingly implementing EHRs and other related health information technology (IT). However, in institutions which have long adopted these computerized systems, such as the Veterans Health Administration, healthcare workers continue to rely on paper to complete their work. Furthermore, insufficient EHR design also results in computer-based workarounds. Using direct observation with opportunistic interviewing, we investigated the use of paper- and computer-based workarounds to the EHR with a multi-site study of 54 healthcare workers, including primary care providers, nurses, and other healthcare staff. Our analysis revealed several paper- and computer-based workarounds to the VA’s EHR. These workarounds, including clinician-designed information tools, provide evidence for how to enhance the design of the EHR to better support the needs of clinicians.

Persuasive health educational materials for colorectal cancer screening

This paper describes an effort to design and evaluate persuasive educational materials for colorectal cancer (CRC) screening. Although CRC screening is highly effective, screening rates in the US remain low. Educational materials represent one strategy for educating patients about screening options and increasing openness to screening. We developed a one-page brochure, leveraging factual information from the Centers for Disease Control and Prevention (CDC) and national guidelines, and strategies for persuasion from the human factors and behavioral economics literatures. We evaluated the resulting brochure with adults over the age of 50. Findings suggest that the educational brochure increases knowledge of CRC and screening options, and increases openness to screening. Furthermore, no significant difference was found between the new one-page brochure and an existing multi-page Screen for Life brochure recommended by the CDC. We interpret these findings as indication that the more practical and potentially less intimidating one-page brochure is as effective as the existing multi-page Screen for Life brochure.

The effect of communication modality and presence of feedback in Command and Control environments

Efficient and effective communication between operators in a Command and Control (C2) environment is essential to mission success. Modern technology affords several communication options. The current study evaluates three of these options: voice, handwritten, and electronic chat. Participants monitored a large display depicting the flights of three UAVs, while simultaneously tracking, on a separate smaller screen, the status of critical performance parameters of the UAVs. Using one of three methods participants communicated key events to a secondary operator. For half the trials, the secondary operator provided feedback (confirmation or request for clarification); for the other half no feedback was given. Performance times, accuracy, and subjective workload data were collected. User preference and familiarity with each form of communication was also evaluated. Initial results indicate a time and accuracy advantage for voice, with feedback providing a speed-accuracy tradeoff. Participant preference was evenly divided in terms of communication technique and presence of feeback

Predicting Complex Spatial Working Memory Fatigue Vulnerability Based on Individual Differences in fMRI Images

The effects of mental and physical fatigue can significantly impact how we interact with our daily environment. Furthermore, these effects exhibit a high level of variance across individuals. Advances in technologies such as functional magnetic resonance imaging (fMRI) are offering new opportunities to characterize the effects of sleep deprivation on individuals. In this paper, we investigate the use of advanced fMRI modalities in resting wakefulness as correlated with performance on a spatial working memory task after sleep deprivation. Findings show that fatigue vulnerability to performance decrements on complex spatial working memory tasks in healthy participants can be predicted by fMRI images taken during resting wakefulness.

Self-Report Methods for Cambridge Neurological Test Battery (CANTAB) strategies

Self-report measures represent an important means to augment brain activation studies by providing important insight into participant strategies for completing cognitive tasks. Triangulating self-report data with brain scans and performance data promises to yield a more complete picture of brain activity (Jack & Roepstorff, 2002). The current exploratory study investigated the feasibility of using self-report measures following performance on two Cambridge Neurological Test Battery (CANTAB) inventories: The Delayed Match to Sample and the Cambridge Gambling Task. In this study, we obtained written and spoken descriptions of strategies used to complete the CANTAB tasks. We found that participants were comfortable reporting strategies. There were commonalities, as well as idiosyncratic strategies for completing the two inventories across eight participants. Next steps include linking reported strategies with performance to determine how descriptive self-reports correlate with actual behavior. In addition, approaches to developing alternative means of self-report for studies of brain function under stress are discussed.

Maintaining Vigilance with Auditory and Visual Cues in Command and Control Environments

The current study evaluates the use of auditory and visual stimuli as cues to prompt the shift of attention between small screen and large screen displays in a Command and Control (C2) environment. The use of spatial audio displays has been shown to reduce workload and improve target detection times. This design employed a two-screen model with multiple targets as well as a multimodal cuing strategy. Ten participants completed eight monitoring task sessions consisting of four different cuing conditions: no cuing, auditory cuing, visual cuing, and combined auditory and visual cuing. Reaction times and accuracy rates, in addition to perceived workload and preference, were compared across all four conditions. It was found that visual cues, auditory cues, and the combined presentation of visual and auditory cues, resulted in faster response times when compared to no cuing. No differences were found between prompting types. The findings of this study apply to the C2 environment, as well as other multi-task environments that may require time-sensitive responses to events and information represented on multiple visual displays.