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Functional workstation requirements: clinical perspectives
Bio#edical ELSEVIER SCIENCE lRELAND
International Journal of Bio-Medical Computing 34 (1994) 115-121
Functional workstation requirements: clinical perspectives Robert
M. Kolodner
‘Department of Veterans Affairs Medical Center 4500 South Lancaster Road, Dallas, TX 75216, USA bDepartment of Psychiatry The University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA
Abstract
This white paper details specific requirements for clinical workstations identified by employees in the Department of Veterans Affairs. The requirements can be grouped into the following five categories: general environmental capabilities, input methods, display features, output abilities, and miscellaneous functionality and features. Clinical workstations meeting these functional requirements can offer a significant enhancement over existing hardware interfaces. Use of these workstations by health care providers could improve their willingness to directly enter data into clinical information systems, increasing the benefits of such systems. Key words:
Computers; Medical record systems, computerized
1. Introduction Benefits from the use of automated Clinical Information Systems significantly increase when health care providers enter all of their clinical information directly, without having intermediaries transcribe information from encounter form, handwritten, or voice entry methods. While more clinical information is already being entered directly, in most facilities data entry by clinicians is not universal, and those who do enter information do not usually enter all of their notes, orders, histories, physical examinations, etc. In particular, physicians have been the most reluctant group to directly enter clinical data into computers. Although many reasons have
* Corresponding author, Chief Medical Informatics (I 1B), VA Medical Center, 4500 South Lancaster Road, Dallas, TX 75216, USA. 0020-7101/94/$07.00 0 1994 SSDI 0020-7 10 1(94)00902-T
Elsevier Science Ireland Ltd. All rights reserved
116
R.M. Kolodner /ht.
J. Biomed. Compur. 34 (1994)
115-121
been given for this resistance, one major barrier has been that current data entry methods do not yet meet clinical needs enough to entice providers to adopt them. This white paper details specific requirements for clinical workstations that were identified by members of the Clinical Record Special Interest Users Group of the Department of Veterans Affairs (VA). These requirements were incorporated into the ‘Clinical Record Concept Paper’ commissioned by the VA and delivered by Booz Allen & Hamilton in 1990. The term ‘workstation’ is used to refer generically to any intelligent device (such as desktop, notebook, or pen-based microcomputer, or highend, RISC-based computer) that might be used by a clinician to enter and retrieve clinical information. The requirements will be presented by grouping them into five categories, although these categories are not mutually exclusive. These five categories are as follows: general environmental capabilities, input methods, display features, output abilities, and miscellaneous functionality and features. 2. Environmental capabilities 2.1. General environmental capabilities Standard, easy environment
A standard, easy-to-use environment is an essential characteristic of the clinical workstation. Users should not need to learn different methods for interacting with their systems whenever it is upgraded or whenever they work in multiple health care locations with different vendor-supplied information systems. Training costs and learning curves are kept to a minimum by operating within standards and conventions that are common across all systems. Competition can continue on the level of additional features and capabilities that are included by vendors. Among current computer-based interfaces, a Graphical User Interface (GUI) offers the best example of such a potential environment, despite the variation in specific implementations of these interfaces across operating systems and software vendors. User-definable modifications
Although environments should be standardized, they should include the capability of being tailored to meet users’ needs. A hallmark of a good clinical workstation environment is the incorporation of tools to allow providers to define specific views of clinical information that they prefer to use. This is analogous to the way that users can define the specific organization of objects and programs on a desktop they wish to see when using Microsoft Windows@ or an Apple Macintosh@. Clinicians should be able to make these changes without any need to program and to quickly and easily choose and arrange the view they want and save it for later retrieval. Multiple views, available on any device
In fact, clinical data should be retrievable from several points of view, such as by patient, by team list, by clinic schedule, by ward layout, or by scheduled tests or patient activities. Users may want to define different views to use in different settings (clinic, inpatient ward, nursing home, administrative office) or different types of clinical interactions (intake of a cardiac patient, emergency room evaluation of a
R.M. Kolodner /ht.
J. Biomed. Comput. 34 (1994)
115-121
117
patient with chest pain, follow-up of a patient after prostatectomy for cancer). Moreover, these views should be available wherever the user is located, and not be limited to a specific device, device type, or device location. Thus, these views should be supported on any clinical system on which the clinician has access, within the limits of the features offered by that system vendor. 2.2. Specific environmental capabilities User-definable objects and arrangements
Clinicians should be able to change a variety of parameters within their environment such as the icons or pictures used to record or retrieve signs, symptoms, and physical examination data, and the default view. Additional flexibility should be available within each view. For example, users should be able to select the colors of the display (if applicable) and to arrange the objects displayed on the screen, including the size and placement of windows. User-controllable data features
Within a window, users should be able to further modify and control the way that information is displayed. They should be able to control data placement and appearance, choose how they want to be notified when new information is available, reverse left and right in timelines and graphs with the click of a button, switch columns and rows of data in tables, designate the format of date and time fields, and specify the highlighting characteristics (bold, italics, color) to be used for categories of data (abnormal results, unverified patient-entered information, etc.)
3. Input methods 3.1. Multiple input modalities Users should be able to interact with the computer using a variety of input modalities. Keyboards, pointing devices (mice, light pens, pens, fingers), bar code readers, and voice should be supported where appropriate. Different users might use different input methods for the same tasks, and a given user might use a variety of methods for different tasks. This versatility permits users to select the method that allows them to be most comfortable and efficient at both controlling the computer system and entering the large volume of clinical information necessary in order to create a computer-based patient record. 3.2. Software that facilitates data input The software that is designed for clinical data entry should facilitate the rapid entry of clinical information. Although the specific techniques for accomplishing this will change over time, current examples of such techniques include the use of structured menu choices that dynamically change to contain the most common items entered by the user and the inclusion of a method for annotating data with a ‘post-it’ note that might contain text, graphics, or audiovisual information.
118
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J. Biomed. Comput. 34 (1994) 115-121
4. Display features 4.1. Graphing data, ‘drill-down ’for details As alluded to earlier, several display features are required on the clinical -workstation. First, users should be able to easily graph any clinical data appropriate for graphical presentation. Second, data should be organized so that users can pointand-click on a test result or procedure summary in order to ‘drill-down’ and obtain detailed information, such as a full text report. Some vendors might even combine graphic and text capabilities by summarizing a patient’s lifetime history on a timeline, with icons for significant events and clinical encounters. Users might ‘drilldown’ by selecting an icon to retrieve more information regarding these events and encounters. 4.2. Multimedia support
As multimedia materials are incorporated into the clinical systems, users should be able to click on a radiology report to view the X-ray image on a high-resolution display or the video image of a cardiac catheterization. 4.3. Ability to open multiple windows simultaneously In addition, users should be able to open multiple windows at the same time. Use of side-by-side windows promotes comparison of information, similar to placing pages of information next to one another on a desk or to entering patient orders in a chart while viewing the patient’s progress notes and laboratory results. One window might also access resource information such as bibliographic data or reference material, outlined below, in addition to viewing and manipulating individual patient data in another window. Using windows, users also gain the freedom to define their own work processes and not be locked into a programmer-defined method for accomplishing a task. For instance, a user might successively open windows to (i) begin entering orders, (ii) review the patient’s problem list, (iii) view two different renal test results and the patient’s body weight graphed on the same axis over time, and (iv) calculate the proper medication dose for the patient, plugging the result into the first window, completing the order. Thus, users will be able to chose what they want to do next, where they want to write, and what they want to view, just as they can now when they are working with the paper-based medical record. Computers should not reduce their capabilities, but instead should enhance them. 5. Output abilities 5.1. What you see is what you get (WYSIWYG)
capability
Not only should users be able to display patient information and reports on their workstation, but they should be able to generate paper copies as well. Clinicians
R.M.
Kolodner /ht.
J. Biomed. Comput. 34 (1994)
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119
should be able to control the way these reports look and the layout of information on each page to highlight critical data and maximize the report’s usefulness by having the WYSIWYG display on their screen. Additionally, users should be able to transmit to remote sites either the reports or the clinical data and images themselves, including any annotations they wish to add. This would be used for synchronous or asynchronous clinical consultations with colleagues located at other sites, for teaching and Grand Rounds presentations, or for transfer of data when a patient is receiving care, temporarily or permanently, at another facility. Appropriate security would be used in the transfer of sensitive clinical information. 6. Miscellaneous
functionality
and features
Clinical workstations should support functionality and contain features in addition to those noted above. Eight such functions and features will be reviewed in this section. 6.1. Rapid system response
Systems should have a rapid response rate. The actual response speed can vary depending upon the task. For data entry and error checking, response should be essentially instantaneous. Data retrieval for an individual patient should occur within l-2 s. Retrieval of other clinical and reference information could be slower, but maximum times would need to be determined by working closely with the user community. 6.2. Cut and paste ability
Users should be able to cut and paste text across windows. Pasting would be possible into appropriate data fields, which would apply the same error checking to the pasted information as would be applied if the information had been typed via the keyboard. This would allow providers to use any word processor that runs under the workstation’s operating system without limiting them only to one included with the clinical information software. 6.3. Dynamically-update clinical information
Clinicians should have the option of having the workstation update clinical patient information dynamically. Thus, a graph could be kept up-to-date with the most current data or could be ‘frozen’ as a snapshot in time, depending upon the user’s selection. 6.4. Support aggregate data searches
The workstation should have access to tools to allow for aggregate data searches across patients, both at the local facility and in remote clinical data banks to which
120
R.M. Kolodner /ht.
J. Biomed. Comput. 34 (1994)
115-121
the user has access. This function may be dependent upon the underlying systems, but a well-designed workstation may provide the tools with which to make these inquiries easy for the clinician to construct. 4.5. E-mail support
Clinicians will make better, more regular use of electronic mail resources if the workstation is seamlessly integrated into all E-mail systems to which they have an account. Workstation-based software that intelligently receives and handles E-mail, and that actively polls those systems that might require log-on to retrieve new mail, would greatly simplify a user’s tasks. 6.6. Background retrieval and non-patient-specific data sources
Clinical workstations should have access to a variety of non-patient data banks such as reference materials, bibliographic databases and full-text retrieval brokers for use whenever the clinician needs them. Depending upon the sophistication of the retrieval software, users might open a window and interact directly to retrieve the desired information or they might simply ‘tire off an asynchronous inquiry, which will be processed in the background, notifying them with an auditory or visual signal when the requested information had arrived back at their workstation. 6.7. User-definable alert characteristics
In addition to requests for information, a variety of decision support tools should be available on the workstation. Although the specific set of decision support features is dependent upon the clinical information software, reminders, alerts, and priority messages should display on the provider’s workstation in a manner that can be controlled by the provider herself. She might choose to have the message appear in the form of a pop-up window, as a periodic audio signal, as an icon in the upper portion of the screen, or as a change in the shape, size, color, or blink rate of the cursor. Thus, the system recognizes this category of message and might distinguish levels of importance or priorities within it, allowing the user to define how each is displayed. 6.8. Patient use of workstations
In addition to being used by clinicians, workstations should be designed to facilitate direct use by patients. The devices could be used both for data acquisition from patients and their significant others and for providing individualized patient and family education. As an additional aid in documentation, a record of the patient’s interaction with the education modules, and his performance during the interactive portions could be recorded in his clinical record. 7. Summary
Clinical workstations can offer a significant enhancement over existing hardware
R.M. Kolodner /ht.
J. Biomed. Comput. 34 (1994)
115-121
121
interfaces for use by clinicians. Attention needs to be given to the functional characteristics that should be included to ensure that the resulting workstation meets the needs of clinicians. 8. Acknowledgements
This paper represents the ideas and dedicated work performed both by staff at Booz Allen & Hamilton and by the volunteer efforts of VA staff on the Clinical Record Special Interest Users Group and at the Salt Lake City Information Systems Center. The following VA participants were especially noteworthy for the time and effort they dedicated in addition to their regular duties: Ken Dickie, Joan Gilleran, Doug Gottfredson, James Laub, Ginger Price, Deborah Price, and Deborah Trost.
International Journal of Bio-Medical Computing 34 (1994) 115-121
Functional workstation requirements: clinical perspectives Robert
M. Kolodner
‘Department of Veterans Affairs Medical Center 4500 South Lancaster Road, Dallas, TX 75216, USA bDepartment of Psychiatry The University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA
Abstract
This white paper details specific requirements for clinical workstations identified by employees in the Department of Veterans Affairs. The requirements can be grouped into the following five categories: general environmental capabilities, input methods, display features, output abilities, and miscellaneous functionality and features. Clinical workstations meeting these functional requirements can offer a significant enhancement over existing hardware interfaces. Use of these workstations by health care providers could improve their willingness to directly enter data into clinical information systems, increasing the benefits of such systems. Key words:
Computers; Medical record systems, computerized
1. Introduction Benefits from the use of automated Clinical Information Systems significantly increase when health care providers enter all of their clinical information directly, without having intermediaries transcribe information from encounter form, handwritten, or voice entry methods. While more clinical information is already being entered directly, in most facilities data entry by clinicians is not universal, and those who do enter information do not usually enter all of their notes, orders, histories, physical examinations, etc. In particular, physicians have been the most reluctant group to directly enter clinical data into computers. Although many reasons have
* Corresponding author, Chief Medical Informatics (I 1B), VA Medical Center, 4500 South Lancaster Road, Dallas, TX 75216, USA. 0020-7101/94/$07.00 0 1994 SSDI 0020-7 10 1(94)00902-T
Elsevier Science Ireland Ltd. All rights reserved
116
R.M. Kolodner /ht.
J. Biomed. Compur. 34 (1994)
115-121
been given for this resistance, one major barrier has been that current data entry methods do not yet meet clinical needs enough to entice providers to adopt them. This white paper details specific requirements for clinical workstations that were identified by members of the Clinical Record Special Interest Users Group of the Department of Veterans Affairs (VA). These requirements were incorporated into the ‘Clinical Record Concept Paper’ commissioned by the VA and delivered by Booz Allen & Hamilton in 1990. The term ‘workstation’ is used to refer generically to any intelligent device (such as desktop, notebook, or pen-based microcomputer, or highend, RISC-based computer) that might be used by a clinician to enter and retrieve clinical information. The requirements will be presented by grouping them into five categories, although these categories are not mutually exclusive. These five categories are as follows: general environmental capabilities, input methods, display features, output abilities, and miscellaneous functionality and features. 2. Environmental capabilities 2.1. General environmental capabilities Standard, easy environment
A standard, easy-to-use environment is an essential characteristic of the clinical workstation. Users should not need to learn different methods for interacting with their systems whenever it is upgraded or whenever they work in multiple health care locations with different vendor-supplied information systems. Training costs and learning curves are kept to a minimum by operating within standards and conventions that are common across all systems. Competition can continue on the level of additional features and capabilities that are included by vendors. Among current computer-based interfaces, a Graphical User Interface (GUI) offers the best example of such a potential environment, despite the variation in specific implementations of these interfaces across operating systems and software vendors. User-definable modifications
Although environments should be standardized, they should include the capability of being tailored to meet users’ needs. A hallmark of a good clinical workstation environment is the incorporation of tools to allow providers to define specific views of clinical information that they prefer to use. This is analogous to the way that users can define the specific organization of objects and programs on a desktop they wish to see when using Microsoft Windows@ or an Apple Macintosh@. Clinicians should be able to make these changes without any need to program and to quickly and easily choose and arrange the view they want and save it for later retrieval. Multiple views, available on any device
In fact, clinical data should be retrievable from several points of view, such as by patient, by team list, by clinic schedule, by ward layout, or by scheduled tests or patient activities. Users may want to define different views to use in different settings (clinic, inpatient ward, nursing home, administrative office) or different types of clinical interactions (intake of a cardiac patient, emergency room evaluation of a
R.M. Kolodner /ht.
J. Biomed. Comput. 34 (1994)
115-121
117
patient with chest pain, follow-up of a patient after prostatectomy for cancer). Moreover, these views should be available wherever the user is located, and not be limited to a specific device, device type, or device location. Thus, these views should be supported on any clinical system on which the clinician has access, within the limits of the features offered by that system vendor. 2.2. Specific environmental capabilities User-definable objects and arrangements
Clinicians should be able to change a variety of parameters within their environment such as the icons or pictures used to record or retrieve signs, symptoms, and physical examination data, and the default view. Additional flexibility should be available within each view. For example, users should be able to select the colors of the display (if applicable) and to arrange the objects displayed on the screen, including the size and placement of windows. User-controllable data features
Within a window, users should be able to further modify and control the way that information is displayed. They should be able to control data placement and appearance, choose how they want to be notified when new information is available, reverse left and right in timelines and graphs with the click of a button, switch columns and rows of data in tables, designate the format of date and time fields, and specify the highlighting characteristics (bold, italics, color) to be used for categories of data (abnormal results, unverified patient-entered information, etc.)
3. Input methods 3.1. Multiple input modalities Users should be able to interact with the computer using a variety of input modalities. Keyboards, pointing devices (mice, light pens, pens, fingers), bar code readers, and voice should be supported where appropriate. Different users might use different input methods for the same tasks, and a given user might use a variety of methods for different tasks. This versatility permits users to select the method that allows them to be most comfortable and efficient at both controlling the computer system and entering the large volume of clinical information necessary in order to create a computer-based patient record. 3.2. Software that facilitates data input The software that is designed for clinical data entry should facilitate the rapid entry of clinical information. Although the specific techniques for accomplishing this will change over time, current examples of such techniques include the use of structured menu choices that dynamically change to contain the most common items entered by the user and the inclusion of a method for annotating data with a ‘post-it’ note that might contain text, graphics, or audiovisual information.
118
R.M. Kolodner/Int.
J. Biomed. Comput. 34 (1994) 115-121
4. Display features 4.1. Graphing data, ‘drill-down ’for details As alluded to earlier, several display features are required on the clinical -workstation. First, users should be able to easily graph any clinical data appropriate for graphical presentation. Second, data should be organized so that users can pointand-click on a test result or procedure summary in order to ‘drill-down’ and obtain detailed information, such as a full text report. Some vendors might even combine graphic and text capabilities by summarizing a patient’s lifetime history on a timeline, with icons for significant events and clinical encounters. Users might ‘drilldown’ by selecting an icon to retrieve more information regarding these events and encounters. 4.2. Multimedia support
As multimedia materials are incorporated into the clinical systems, users should be able to click on a radiology report to view the X-ray image on a high-resolution display or the video image of a cardiac catheterization. 4.3. Ability to open multiple windows simultaneously In addition, users should be able to open multiple windows at the same time. Use of side-by-side windows promotes comparison of information, similar to placing pages of information next to one another on a desk or to entering patient orders in a chart while viewing the patient’s progress notes and laboratory results. One window might also access resource information such as bibliographic data or reference material, outlined below, in addition to viewing and manipulating individual patient data in another window. Using windows, users also gain the freedom to define their own work processes and not be locked into a programmer-defined method for accomplishing a task. For instance, a user might successively open windows to (i) begin entering orders, (ii) review the patient’s problem list, (iii) view two different renal test results and the patient’s body weight graphed on the same axis over time, and (iv) calculate the proper medication dose for the patient, plugging the result into the first window, completing the order. Thus, users will be able to chose what they want to do next, where they want to write, and what they want to view, just as they can now when they are working with the paper-based medical record. Computers should not reduce their capabilities, but instead should enhance them. 5. Output abilities 5.1. What you see is what you get (WYSIWYG)
capability
Not only should users be able to display patient information and reports on their workstation, but they should be able to generate paper copies as well. Clinicians
R.M.
Kolodner /ht.
J. Biomed. Comput. 34 (1994)
115-121
119
should be able to control the way these reports look and the layout of information on each page to highlight critical data and maximize the report’s usefulness by having the WYSIWYG display on their screen. Additionally, users should be able to transmit to remote sites either the reports or the clinical data and images themselves, including any annotations they wish to add. This would be used for synchronous or asynchronous clinical consultations with colleagues located at other sites, for teaching and Grand Rounds presentations, or for transfer of data when a patient is receiving care, temporarily or permanently, at another facility. Appropriate security would be used in the transfer of sensitive clinical information. 6. Miscellaneous
functionality
and features
Clinical workstations should support functionality and contain features in addition to those noted above. Eight such functions and features will be reviewed in this section. 6.1. Rapid system response
Systems should have a rapid response rate. The actual response speed can vary depending upon the task. For data entry and error checking, response should be essentially instantaneous. Data retrieval for an individual patient should occur within l-2 s. Retrieval of other clinical and reference information could be slower, but maximum times would need to be determined by working closely with the user community. 6.2. Cut and paste ability
Users should be able to cut and paste text across windows. Pasting would be possible into appropriate data fields, which would apply the same error checking to the pasted information as would be applied if the information had been typed via the keyboard. This would allow providers to use any word processor that runs under the workstation’s operating system without limiting them only to one included with the clinical information software. 6.3. Dynamically-update clinical information
Clinicians should have the option of having the workstation update clinical patient information dynamically. Thus, a graph could be kept up-to-date with the most current data or could be ‘frozen’ as a snapshot in time, depending upon the user’s selection. 6.4. Support aggregate data searches
The workstation should have access to tools to allow for aggregate data searches across patients, both at the local facility and in remote clinical data banks to which
120
R.M. Kolodner /ht.
J. Biomed. Comput. 34 (1994)
115-121
the user has access. This function may be dependent upon the underlying systems, but a well-designed workstation may provide the tools with which to make these inquiries easy for the clinician to construct. 4.5. E-mail support
Clinicians will make better, more regular use of electronic mail resources if the workstation is seamlessly integrated into all E-mail systems to which they have an account. Workstation-based software that intelligently receives and handles E-mail, and that actively polls those systems that might require log-on to retrieve new mail, would greatly simplify a user’s tasks. 6.6. Background retrieval and non-patient-specific data sources
Clinical workstations should have access to a variety of non-patient data banks such as reference materials, bibliographic databases and full-text retrieval brokers for use whenever the clinician needs them. Depending upon the sophistication of the retrieval software, users might open a window and interact directly to retrieve the desired information or they might simply ‘tire off an asynchronous inquiry, which will be processed in the background, notifying them with an auditory or visual signal when the requested information had arrived back at their workstation. 6.7. User-definable alert characteristics
In addition to requests for information, a variety of decision support tools should be available on the workstation. Although the specific set of decision support features is dependent upon the clinical information software, reminders, alerts, and priority messages should display on the provider’s workstation in a manner that can be controlled by the provider herself. She might choose to have the message appear in the form of a pop-up window, as a periodic audio signal, as an icon in the upper portion of the screen, or as a change in the shape, size, color, or blink rate of the cursor. Thus, the system recognizes this category of message and might distinguish levels of importance or priorities within it, allowing the user to define how each is displayed. 6.8. Patient use of workstations
In addition to being used by clinicians, workstations should be designed to facilitate direct use by patients. The devices could be used both for data acquisition from patients and their significant others and for providing individualized patient and family education. As an additional aid in documentation, a record of the patient’s interaction with the education modules, and his performance during the interactive portions could be recorded in his clinical record. 7. Summary
Clinical workstations can offer a significant enhancement over existing hardware
R.M. Kolodner /ht.
J. Biomed. Comput. 34 (1994)
115-121
121
interfaces for use by clinicians. Attention needs to be given to the functional characteristics that should be included to ensure that the resulting workstation meets the needs of clinicians. 8. Acknowledgements
This paper represents the ideas and dedicated work performed both by staff at Booz Allen & Hamilton and by the volunteer efforts of VA staff on the Clinical Record Special Interest Users Group and at the Salt Lake City Information Systems Center. The following VA participants were especially noteworthy for the time and effort they dedicated in addition to their regular duties: Ken Dickie, Joan Gilleran, Doug Gottfredson, James Laub, Ginger Price, Deborah Price, and Deborah Trost.