Interface Design for Clinical Information Systems: An Ecological Interface Design Approach Kip C,~eld, Phi9 Kerry Petrucci, Phi3 CRNP Laboratory for Healthcare Informatics Department of Information Systems University of Maryland, UMBC Baltimore, MD 21228 USA [email protected] Department of Physiological Nursing School of Nursing University of Washington Seattle, WA USA petrucci@ u_washington.edu Abstract. This paper uses results from research in Clinical Information Systems (CIS) design, the psychology of clinical reasoning, and Ecological Interface Design (EID) to motivate general design concepts for the human- computer interface of CIS for ambulatory care, There are three primary contributions of this paper to the fields of HCI and Healthcare Informatics. (1) EID is generalized to the very different complex domain of healthcare decision making, (2) The previous work in clinical domain modeling informs the interface design principles of FAD, (3) EID holds together a top-down theoretical approach to interface design and a bottom-up approach from specific domains. A specific design for an implemented ambulatory care CIS for geriatrics is used to illustrate the generality of FAD. 1. Introduction This paper uses results from research in Clinical Information Systems (CIS) design, the psychology of clinic,'d re~oning, and Ecological Interface Design 0EID) to motivate general design concepts for the human-computer interface of a CIS for ambulatory care. Each area is reviewed below and then their impacts on our specific CIS design project are discussed. EID is used as a framework to explore design issues that are domain-oriented and user-oriented. Other frameworks address some of the same issues and are equally valuable at this high level such as the domain-specific cooperative systems of Fischer [5] or Participatory Design [8]. 1.1 Clinical Information Systems Computer-based patient records (CPR) are now practical because of advances in computer technology and a steady decline in hardware prices. They ,are not very commonplace in current medical practice, where paper medical records ,are still the standard. This section discusses: o o The need for CPR in ambulatory care. The problems in acceptance and development of CPR.392 The issues involved in designing and delivering CPR for health care organizations are at their most basic, clinical concerns. Clinical providers are the ones who must record and consume clinical information. Most direct productivity of such organizations is based on the actions of clinical providers. If those providers can better document ,and better use clinical information, the productivity of the organization can be significantly improved. The major areas that drive the need for CPR ,are: More emphasis on chronic disease. Management benefits (Cost, QA). Benefits to patient care. As the population ages there are more chronic disease conditions for clinicians to manage. Chronic disease is usually managed in ambulatory care settings and requires continuity of care. This continuity is provided by the medical record. Healthcare costs are widely considered to be out of control. There is great pressure to increase the reporting requirements for governmental and insurance reimbursement. The great failure of many current computer-based reporting programs is that they are geared only for administrative purposes and are of no direct use to clinicians who are in the best position to document patient states. Management benefits include: quality assurance, protocol standardization, practice management, resource management. These tasks can use the historical database from a CIS to track resource utilization for future planning and strategic management. For example, one could do a "problem-oriented" audit of resource utilization if there were links between medical orders and documented patient problems [1]. This means that one could track how much named resource was consumed per problem as def'med for the analysis. The major benefit to patient care is better communications for patients and interdisciplinary providers. Independence from the single physical paper record allows better access to patient information. Reporting flexibility reduces double data entry. Alerts, reminders, and decision support systems give providers and managers control over process in the clinical setting. The following problems impede the development of CPR: o Dam entry o Provider compliunce Data entry is one of the biggest obstacles for CPR. Dam entry is usually done indirectly in current record systems. Providers fill out encounter sheets or dictate findings ,and then data entry personnel enter the data into the computer. This393 indirect entry system has major drawbacks such ,as the errors due to lack of provider control and the fact that no interactive applications are possible, Provider compliance is a function of both clinical relevance and ease of data entry. Most current systems separate the documentation of clinical states for medical management and administrative reporting. Providers then see documentation ,as a chore that does not give them clinical advantages. With CPR, the information is used for clinical patient management and can feed all information needs for reimbursement because billable items are a subset of the clinically needed information. The CIS described below attempts to remedy the problems of use and compliance with an interface that presents a useful clinical information tool- not just a documentation task. The major impediments to CPR are not technological, but ones of organizational practice. -- 1.2 Clinical Reasoning There has been a tremendous amount of research into the nature of clinical reasoning by healthcare providers, but that research has had little impact on interface design. Two major areas are briefly (and incompletely) reviewed below: o Clinical information. o Clinical expertise. A major theoretical stud); of the nature of medical information is found in Blois [2]. He reviews the structure of medical descriptions and pays special attention to the nature of hierarchical