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Mapping the Electronic Health Record: A Method to Study Display Fragmentation
Yalini Senathirajaha, Jinglu Wangb, Elizabeth Boryckic, Andrek Kushnirukc
a Department of Medical Informatics, SUNY Downstate Medical Center, Brooklyn, NY, USA, b Weill Cornell Medical School, Cornell University, New York, NY, USA
c University of Victoria, Victoria, Canada
Abstract
Electronic health records have often been criticized for poor
interaction design. One major problem is the ‘display
fragmentation problem’ i.e. the fact that conventional EHRs
require the user to view many screens and retain information
in memory or external tools rather than being able to view all
relevant information together, increasing cognitive load and
the possibility of errors and inefficiency. We describe a
method for evaluating and depicting the extent of display
fragmentation and discuss its potential uses in comparing
systems, identifying navigation pathways and information
juxtaposition, and improving EHR interaction design.
Keywords:
Electronic Health Records; User-Computer Interface;
Computer Graphics.
Introduction
Healthcare information technology (‘health IT’) and electronic
health records (EHRs) have great promise to improve care,
reduce costs, and create a ‘learning healthcare system’ in
which continuous improvement is possible by using data to
analyze which treatments are most effective. However,
optimal interaction design of such software has proven
difficult, with the potential for health IT to introduce safety
concerns.
The Institute of Medicine 2011 report [1] identifies several
concerns related to fragmented displays and the conventional
interaction approach in which information location is fixed by
the programmer and users navigate through menus. These
concerns include the mismatch between programmer
assumptions and actual work environment and the mismatch
between developer and clinician backgrounds, resulting in
unmet needs. Current displays may not reflect clinical
associations, presenting related data separately. Activities are
treated as belonging to individual clinicians, instead of to a
sociotechnical system with many intercommunicating
components and unpredictable ways [1]. Inflexible order
sequences may require providers to hold orders in mind while
navigating, and time spent on cumbersome data retrieval and
remodeling is time taken from other clinical demands [1].
Display fragmentation occurs in conventional systems when
the end user must click through and view many different
screens or parts of screens in order to view all the relevant
clinical information. This necessitates sequential viewing and
requires retaining information in memory while other parts of
the information are sought. The end user must often then serve
as the ‘de facto integrating agent’ [1], integrating information
in mind rather than using external tools. This is a known cause
of excessive cognitive load and may impair optimal clinical
reasoning performance and other aspects of clinical cognition.
Addressing the display fragmentation problem is therefore an
important task in redesigning clinical information systems for
better efficiency and cognitive support.
Prior work reveals conventional EHRs have an approximate
six-fold greater number of clicks and screen transitions
required to obtain complete information [2] than systems in
which the relevant information for a task can be included on
one screen. Conversely, appropriate information juxtaposition
can foster insight, creativity, sensemaking, and problem-
solving [3,4].
Modular composable systems
Because the display fragmentation problem arises partly from
the fact that information location is typically fixed by the
programmer, one means of addressing it is to by making
systems a) modular (i.e. pieces can be rearranged and
reassembled flexibly according to different needs, like a Lego
set), and b) composable by the end user clinician. Removing
the requirement for a programmer to reconfigure displays and
giving the clinician the ability to assemble any desired
elements together on the same screen can allow patient-
specific display of all relevant information on the same page,
reducing cognitive load and respecting clinicians’ deep
medical expertise in their choice of elements. Ease of use can
mean that drag/drop assembly of ‘objects’ is a simple means
of providing this functionality. Some other domains in which
user expertise and security/reliability are important have also
used this approach; NASA mission control tools are an
example [5].
MedWISER system
Our experimental system, MedWISER, implements a modular
composable architecture, in which elements are backed by a
controlled vocabulary [6]. Separation of the display elements
and back-end data queries allows for a javascript framework
which permits the end user to specify display of chosen
elements (such as a lab value, note or note fragment, mashup
of lab plots, RSS feed) in movable rectangular widgets. These
can also be opened to large-screen size, collapsed with only a
header showing, colored, retitled, and have other
modifications which affect display. This gives the end user
considerable power to select and arrange information elements
[7]. More advanced features are not discussed in this paper.
By permitting choice and assembly of any elements by the
clinician, these can be gathered on the same page before or
during clinical review of the patient case. This then avoids the
fragmentation problem, as repeated navigation to and viewing
of other screens is no longer necessary (or minimally
necessary). This should avoid the consequent cogntive load,
forgetting, navigation ineffiencies and other problems inherent
in our current conventional fixed systems. These typically
MEDINFO 2017: Precision Healthcare through InformaticsA.V. Gundlapalli et al. (Eds.)
© 2017 International Medical Informatics Association (IMIA) and IOS Press.This article is published online with Open Access by IOS Press and distributed under the terms
of the Creative Commons Attribution Non-Commercial License 4.0 (CC BY-NC 4.0).doi:10.3233/978-1-61499-830-3-1138
1138
present the user with a series of tabs, left-hand menus, drop-
down lists or other affordances allowing the user to find and
view different pieces of information configured as a
hierarchical tree, with higher level menus providing access to
more granular information as the tree is traversed.
One way to study and compare systems is to map the locations
of the major information elements as they occur according to
the navigation structure of the EHRs. This can help us
understand the fragmentation problem, suggest design
solutions, and compare systems. Here we describe a method of
doing this, with a few examples.
Methods
Modified Cognitive Walkthrough
Cognitive walkthrough is an expert-based, usability evaluation
method for identifying usability issues. The expert steps
through a typical task, noting all navigation actions, system
responses, and potential problems, according to well-
established heuristics and expert knowledge. We make use of
this basic technique to map information locations, creating the
navigation tree by walking through each step from the top of
the navigation tree (typically the selection of the specific
patient from a patient list) [8]. An example of a map
subsection appears below.
Sunburst Visualization
Many different visualizations of hierarchical structures exist
with advantages and disadvantages. In this technique we have
leveraged advantages of the sunburst visualization. This
visualization dispays tree structures in a circular fashion (as if
the spine of the tree were wrapped around in a
circle),facilitating display of entire trees in a single page, with
drill down (in interactive versions) to details of leaves. This
facilitates apprehension of the relationships between different
regions, and makes it easier to show navigation pathways in
relation to the overall navigation structures. It also addresses
the problem that as the number of leaves expands more space
is needed, since the deeper levels furthest from the trunk
appear in the outer concentric circles, using the greater
available space.
Microsoft Excel 2016 and other tools generate such displays
from spreadsheets or hierarchical text documents. See Figure
1. Figure 1 (b) shows the sunburst visualization for the tree
section shown in Figure 1 (a).
We use as an example the general information review that
clinicians undertake when reviewing a comprehensive patient
case, in one of the major commercial inpatient systems
(Figures 2 and 3). This generally involves the following types
of information: admission notes, laboratory results, orders,
study reports (e.g. of imaging or other studies), images (if
available), discharge summaries, primary care provider notes,
medications, demographic and insurance data, and nursing
notes (if available) as well as automated data from devices, if
applicable.
In the sunburst, sections at the same navigation level appear in
the same concentric circle; with leaves below toward the outer
rim. Items viewable together on the same screen are included
in the same block (with the names all written together in the
same sector). Items not viewable together on the same screen
Figure 1 - (a) Example tree structure subset for clinical data. The user must go to an orders tab, then select laboratory
tests, then chemistry or microbiology, then view the various test panels and their subelements. (b) Sunburst visualization
for the tree subsection shown in Figure 1(a) Numeric values may be assigned to sectors to show them at various sizes
corressponding to desired parameters. Here, sectors at the same level have equal weight.
(a) (b)
Y. Senathirajah et al. / Mapping the Electronic Health Record: A Method to Study Display Fragmentation 1139
Figure 2 - Sunburst diagram of commercial outpatient system navigation with clinical element leaves shown in black. Each concentric
circle represents a level of navigation from the top of the tree. In this case the majority of clinical element values are at least two
steps (e.g. clicks) from the origin, and are displayed separately on different screens from other clinical elements, requiring the user to
view multiple screens to get a comprehensive clinical overview.
but only sequentially as parts of separate screens accessed
from the same menu level appear as separate sectors adjacent
to each other, in the same colour as the higher menu level.
Figures 2 and 3 show the essential clinical elements coloured
in black. Figure 3 shows the extent of display fragmentation;
with each element in a separate sector if it must be navigated
to separately, permitting analysis of the EHR structure and
where elements are juxtaposed or not.
While figures shown here are relatively simple, visualization
software is capable of rendering hierarchies with thousands of
elements, with drill-down and expansion capabilities to
facilitate examination of relationships between elements,
pathway identification, and the study of subsections.
Quantification of Display Fragmentation
The fact that clinical elements appear in different subsections
of the tree can be quantified, with respect to useful parameters
such as the number of clicks or screen transitions required to
access individual elements (starting from the top of the tree, or
from intermediate points), as well as the likely numbers of
clicks/screen transitions required for typical case review.
Derivation of an expression incorporating these parameters
(including such things as requirements to scroll, or filtering
functions) could allow comparison across commercial
systems, and comparison of whether an interaction design
improvement has successfully reduced the numbers of actions
and fragmentation.
Y. Senathirajah et al. / Mapping the Electronic Health Record: A Method to Study Display Fragmentation1140
Figure 3 - Display fragmentation in a commercial inpatient system. (Clinical review elements only).
A total of 37 clicks is required to access all the elements shown in black.
Results
Initial trials of this method revealed that a majority of end
clinical elements (end leaves) of the navigation tree are
located at least two levels below the top, and that
consequently numbers of clicks and screens may reach dozens
in order to view all relevant information. This echoes
complaints by clinician organizations that ‘too many clicks’
are plaguing physicians in practice and delaying rather than
hastening good use of the EHR and expected efficiencies
[9,10].
Some systems attempt to reduce the problem by having pages
for summaries, with varying degrees of success. Two
problems identified in our preliminary work are the lack of
inclusion of important clinical information in the summary,
and the need for scrolling within elements in the summary,
with uniform presentation of blocks of data regardless of
whether the blocks are populated or not. This has the potential
of wasting space and confusing the user, who may be unaware
that the data exists elsewhere. The display fragmentation
problem still exists where the user must take an action to view
all the data on screen. Roman et al. describe the significance
of within-page and between-page navigation as an important
factor for EHR usability [11]. An example of the first problem
is an outpatient system in which the clinical summary page
includes demographic, billing, encounter and allergy data, but
not other important clinical variables.
Discussion
Comparative studies across commercial and home-grown
EHRs are under way, in order to identify the extent of
fragmentation as a problem in general, and specific design
Y. Senathirajah et al. / Mapping the Electronic Health Record: A Method to Study Display Fragmentation 1141
patterns which may contribute to it or conversely reduce
fragmentation for specific tasks. The advent of mobile EHRs
has also affected the fragmentation in both positive and
negative ways. As mobile screens typically display less
information, designers may have paid more attention to screen
flow in order to ensure correct distribution of clinical values in
a way meaningful and convenient to physicians. They are also
able to make use of design patterns such as sequential tree
menus to focus actions on immediate tasks without extraneous
data. On the other hand, if poorly done, this can increase
fragmentation, given the screen size limits and need to cater to
finger- rather than mouse-driven interaction, which typically
has smaller resolution.
The modified cognitive walkthrough method combined with
sunburst display has several advantages for data collection.
Cognitive walkthrough for the purpose of defining navigation
structures is easy to teach, and easily grasped by non-
researchers, allowing for others such as clinicians with access
to systems to be data collectors. This can facilitate broader
studies as specialized access need not be arranged. The use of
Excel or similar spreadsheets is familiar to most people, and
the branching structure, once explained, is also easy to
understand. Automatic generation of sunburst as one of the
now standard visualizations allows for easy experimentation.
Formatting options allow manual coloring of subsectors. Some
visualization tools generate the path from the top of the tree as
a part of the legend, changing interactively as the user moves
over different elements.
In preliminary studies, users are found to be mostly unfamiliar
with the sunburst (unless their particular work requires it), but
find it relatively simple to understand once its tree structure
basis is explained. Prior empirical work on comparative
information visualization of hierarchical structures has shown
sunburst visualizations to be more efficient for tasks involving
perception of the hierarchy [12], with a shorter learning curve.
Interaction Design Implications and Other Use Cases
Mapping can support composable approaches’ reduction of
fragmentation, and assist creation of safer design patterns,
such as replacements for extensive dropdowns or other
undesireable interaction features. Radial menus, for example,
leverage humans’ good capacity to distinguish small angles.
Mapping of redesigns can provide a measure of progress.
Multiple workflow paths could be overlaid on the map, as a
way of specifying efficient transitions.
EHR display fragmentation maps have other uses besides
research. Interactive sunburst visualizations can be used to
convey the navigation paths to particular elements, facilitating
instruction. It is conceivable that use of maps for comparison
of different EHRs might be used for purchasing processes, as
part of evaluation of whether the system flow can be made to
match workflow needs. In some systems, changes do not
propagate to all areas automatically, and a map could facilitate
any manual changes necessary. Development uses include to
give initial overviews to developers or researchers seeking to
improve workflow, and assessing the effect of software
modifications on navigation structures, and thus likely effects
on time, efficiency, and fit to task.
Conclusions
Display fragmentation is a critical problem for the usability of
the electronic health record, and mapping EHR navigational
structure with visualization presents useful ways to understand
and address it. In addition such maps can be useful for related
purposes such as instruction and software development. The
method will allow comparison of fragmentation across EHRs,
facilitating our understanding.
Acknowledgements
This work is funded by AHRQ 1R01HS023708-01A2.
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Address for correspondence
Corresponding author: Yalini Senathirajah [email protected]
Y. Senathirajah et al. / Mapping the Electronic Health Record: A Method to Study Display Fragmentation1142