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Designing Clinically Useful Systems: Examples from Medicine and Dentistry

Department of Medical Sciences, Medical Informatics and Engineering, Uppsala University, University Hospital, 82:1, SE-751 85 Uppsala, Sweden; sabine.koch{at}medsci.uu.se

	Abstract

TOP Abstract Introduction Methods Results Discussion and Conclusion References

 
Despite promising results in medical informatics research and the development of a large number of different systems, few systems get beyond a prototype state and are really used in practice. Among other factors, the lack of explicit user focus is one main reason.

The research projects presented in this paper follow a user-centered system development approach based on extensive work analyses in interdisciplinary working groups, taking into account human cognitive performance. Different medical and health-care specialists, together with researchers in human-computer interaction and medical informatics, specify future clinical work scenarios. Special focus is put on analysis and design of the information and communication flow and on exploration of intuitive visualization and interaction techniques for clinical information. Adequate choice of the technical access device is made depending on the user’s work situation. It is the purpose of this paper to apply this method in two different research projects and thereby to show its potential for designing clinically useful systems that do support and not hamper clinical work. These research projects cover IT support for chairside work in dentistry (http://www.dis.uu.se/mdi/research/projects/orquest) and ICT support for home health care of elderly citizens (http://www.medsci.uu.se/mie/project/closecare).

KEY WORDS: Dental informatics • home health care • human-computer interaction • medical informatics

	Introduction

TOP Abstract Introduction Methods Results Discussion and Conclusion References

 
Research in medical and dental informatics has resulted in the development of a large number of demonstrators, prototypes, and/or systems. However, many of these research results did not reach clinical practice, since they either never overcame a prototype state or could be used only in restricted settings by a few clinicians. Especially with regard to clinical decision support, there is a general consensus that various systems are little used, even though their potential benefits have been demonstrated repeatedly (Kaplan, 2001). Reasons for the insufficient use in clinical practice may be many: IT systems available in health care today have very rarely taken the end user’s needs into account when developed, but have traditionally been the tools of administrators rather than clinicians. Furthermore, many development projects have been technology-driven instead of focusing on actual user needs, the working environment, and the work process. As a result, a great many isolated systems that are unable to communicate and share information have been developed. In addition, existing projects quite often lack a thorough evaluation of organizational, economic, and health-quality effects, leading to an insufficient base for decision-making during system acquisition. As a consequence, decisions on purchasing a system are, due to economic restrictions, based mainly on possible integration with existing systems, hampering the "come through" of new innovative systems. Better interconnectivity and integration between and among different systems based on open standards and interfaces are on the way. Nevertheless, insufficient user focus, insufficient work process integration, and the lack of user-centered system development still inhibit user acceptance. The lack of good human-computer interfaces, for example, has been identified as a major impediment to the acceptance and routine use of many types of computing systems in health care (Patel and Kushniruk, 1997).

For clinically relevant project results to be achieved, formation of interdisciplinary project teams with experienced professionals from different fields is mandatory. This includes health professionals from different disciplines, medical informaticians, human-computer interaction specialists, and professionals from related domains of interest (e.g., perception psychologists). About 10 years ago, Schneider described the unique chance for dental informatics to learn and profit from the experiences and mistakes made in medical informatics. He claimed motivation and engagement of experienced researchers, educators, and health professionals from various disciplines forming real interdisciplinary project teams to be the key to success (Schneider, 1992). Based on Schneider’s experiences, a method for user-centered system development using a work-scenario-oriented approach is further explored in this paper. It is the purpose of this paper to apply this method in two different research projects and thereby to show its potential for designing clinically useful systems that support and not hamper clinical work.

	Methods

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Health-care professionals have their primary focus on the quality of the care they provide for their patients. Therefore, any health information system developed must be as intuitive and user-friendly as possible to support and not hamper clinical work processes. Usage of existing and modified methods and techniques from the Human-Computer Interaction (HCI) domain—as described, for example, by Nielsen (1994)—are therefore of great value.

The proposed method is based on a general user-centered system development approach (ISO, 1999) and takes both actual user needs and the working environment into account. Interdisciplinary working groups are formed and persist during the entire system development process (Fig. 1). These working groups consist of experienced health domain specialists, medical informaticians, human-computer interaction specialists, and researchers from related or relevant areas, e.g., cognition theory. To analyze different clinical work situations, medical informaticians observe health professionals and participate in their work according to the Master-Apprentice approach (Lave and Wenger, 1991). For identification of user needs, methods like brainstorming, scenario-building, and in-depth interviews are used in iterative seminars. The interdisciplinary working groups define future user-oriented work scenarios and iteratively develop prototypes aimed at analyzing and improving the practical and organizational work as well as identifying user needs and requirements of the forthcoming information technology in different work situations. Paper-based prototypes or demonstrators are used at a very early stage to both analyze and verify user needs, to facilitate communication, and to minimize the risk for misunderstanding between and among working group members with different backgrounds. HCI specialists analyze the users’ cognitive activities in specific work situations with regard to strengths and weaknesses of human cognitive performance. On the basis of such analyses, it is then possible to support and enhance clinical cognitive performance, and thus to improve quality of care. However, appropriate design and implementation of the man-machine interface are crucial. Both the graphic user interface and the mode of interaction with the system have to support human cognitive processing.

View larger version (18K): [in this window] [in a new window]   Fig. 1 — Usage of HCI methods during system development.

	Results

TOP Abstract Introduction Methods Results Discussion and Conclusion References

 
The proposed method has been applied in different research projects so that clinically useful systems could be developed. Two examples are presented in this paper. The first one consists of a project developing IT support for chairside clinical work in dentistry. This project has left its prototype state and is being commercialized and in use today for both clinical work and education. The second project, which is currently ongoing, deals with home health care of elderly citizens. A first test version has recently been implemented.

From research prototype to product: chairside support in dentistry
The European research and development project "ORQUEST—A telematic system for oral health quality enhancement" (http://www.dis.uu.se/mdi/research/projects/orquest) lasted 3.5 years (1996–1999) and resulted in a prototype of a clinical workstation for chairside support in dentistry. ORQUEST provides dentists with a fully integrated clinical workstation with IT support for quality assurance and development in oral health care (Koch et al., 1998b). On the basis of extensive work analyses (Wagner, 1988), and taking into account both physiological- and cognitive-ergonomic principles, the clinical workstation allows for direct access to digital radiography and an intra-oral camera as well as to the software modules needed in a specific clinical context.

It is well-known that the basis of appropriate clinical management is the continuous holistic understanding of a clinical situation. This requires that, at chairside, all clinical information can be immediately accessed, easily managed, and quickly grasped and understood "in one view". "All clinical information" means dental records including medical and dental history, oral status (charting), treatment plan and progress notes, radiographs, and risk factors (Fig. 2).

View larger version (81K): [in this window] [in a new window]   Fig. 2 — The main ORQUEST interface.

View larger version (113K): [in this window] [in a new window]   Fig. 3 — Integration of the ORQUEST prototype into a PLANMECA dental treatment unit.

Usage of clinical products for integrated education
Throughout the world, health-care professionals generally lack knowledge of the possibilities and limitations that informatics and information technology offer to their profession (Haux et al., 1997). Only improved education of health-care professionals can make them more aware of their information needs and increase their knowledge about how medical informatics can support their work.

At the Catholic University of Portugal at Viseu, dental students use parts of the ORQUEST prototype, which were commercialized by Planmeca Oy (Finland), as educational tools for integrated, problem-oriented education with real clinical cases. Furthermore, a European Consortium for Post-Graduate Education in Applied Informatics in Dentistry has been established to educate dentists, teachers from dental schools, dental technicians, hygienists, nurses, employees of dental and insurance companies, and others involved in dentistry with regard to the appropriate use of information technology in dentistry. The Consortium, formed by a group of Dental Schools and other organizations, delivers a wide range of modules on different aspects of applied informatics relevant to dentistry, leading to the award of a European Diploma or Master’s Degree (http://siso.crb.ucp.pt/ediploma).

Academia, public sector, and industry in cooperation: home health care for the elderly
The Swedish research and development project "Technical support for Mobile CloseCare" (http://www.medsci.uu.se/mie/project/closecare) started in August, 2002, and will end in July, 2005. The project focuses on the development and evaluation of work-scenario-oriented ICT support for enhanced home care of elderly citizens. The aim of the project is to provide a seamless and consistent information flow between and among different health-care providers involved in the home care of elderly people and to give intuitive access to information services for the elderly themselves as well as their relatives. This will be achieved by development of a mobile information system that provides correct information in a proper way to the right person at the appropriate occasion of care.

Home care of the elderly today is performed by different types of care providers: medical personnel such as general practitioners or district nurses, and community service personnel in charge of non-medical services, e.g., the patient’s daily hygiene. Even though these care providers, especially the home help service, have a mobile work situation, they very rarely have any mobile IT tools supporting their work. Usually, they either document their respective patient record system at the office or on paper. In addition, different users document in different, often incompatible, base systems. The lack of adequate mobile information access and communication tools clearly hampers the different care providers when it comes to documenting and communicating patient-oriented data. Furthermore, in many countries, e.g., in Sweden, home care of the elderly is shared among different health-care provider organizations. Therefore, a thorough user needs and work analysis, describing the entire work process and the different information and communication flows, is necessary. The results of the user needs analysis in this project specify exactly which information is needed for the different users in specified work situations. The information needed mainly consists of patient-oriented data stored in different health record systems (= base systems) that each care provider maintains for the respective patient. Mobile access to both data of the primary and other care providers’ base systems is mandatory. Different categories of care providers need different views on the entire set of data depending on their work situation. For relevant, context-dependent data to be appropriately filtered, the amount of information stored in the base systems is reduced and ranked in order of priority with respect to user category and work situation. As a result, access will be given to prioritized information in adequate format (PIF) through a virtual health record with different data views for the different user categories (Fig. 4). The design of the graphic user interface is optimized with regard to the respective work situation, the context of use, and the technical device that is used.

View larger version (56K): [in this window] [in a new window]   Fig. 4 — System architecture, "Technical Support for Mobile CloseCare".

	Discussion and Conclusion

TOP Abstract Introduction Methods Results Discussion and Conclusion References

 
The author believes that user-centered system development in interdisciplinary working groups, taking into account human-cognitive performance, allows for a holistic view of the entire work/care process and thereby enhances user acceptance and provides health information systems that are accepted and used in clinical practice. Detailed design and analysis of the information and communication flow in different work situations, in combination with intuitive visualization and interaction techniques, lead to the development of systems that support clinical work processes for different categories of care providers. In addition, system development in interdisciplinary working groups results in a better mutual understanding of different working environments and conditions and the exchange of knowledge and experiences between and among different user groups and users and developers. Furthermore, a continuous educational effect and better understanding of the possibilities and restrictions of information technology for the respective clinical field is provided. This is especially true for user groups that include several health-care professions and for user groups with little experience when it comes to IT and insufficient consciousness of the entire work process.

	Acknowledgments

 
The ORQUEST project has been partly supported by the European Commission, DG XIII, Telematics Application Programme-Health Care, Project No. 1037. Project coordinator, Ina-Veronika Wagner (CMD, Uppsala); technical project management, Werner Schneider and Sabine Koch (CMD, Uppsala). The electronic dental patient record has been developed by Ina-Veronika Wagner and Werner Schneider (CMD, Uppsala) and is now distributed by Planmeca Oy. The decision support system for oral radiology has been developed by Ina-Veronika Wagner and Werner Schneider (CMD, Uppsala), together with Stuart White (UCLA, Los Angeles) and Paul van der Stelt (ACTA, Amsterdam), and is now distributed by Quintessence Publishing Company. The decision support system for oral mucosal lesions has been developed by Manfred Straßburg (University of Düsseldorf), Ina-Veronika Wagner, and Werner Schneider (CMD, Uppsala) and is now distributed by Quintessence Publishing Company. The project "Technical support for Mobile CloseCare" is supported by VINNOVA—Swedish Agency for Innovation Systems (P23037-1 A) and Trygghetsfonden, as well as by the following clinical and industrial partners: Primary Care Hälsingland, County Council of Gävleborg, Municipality of Hudiksvall, DataVis AB, Ericsson Network Technologies AB, Bergsjö Data AB, and AB Hudiksvallsbostäder. Project leader, Sabine Koch (Department of Medical Sciences, Uppsala).

	Footnotes

 
Publication supported by Software of Excellence (Auckland, NZ)

	References

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Wagner I-V, Schneider W (1998). Die interaktive elektronische Krankengeschichte zur Unterstützung im klinischen Management. In: Computer in Zahnarztpraxis und Dentallabor. EDV-Jahrbuch ’98. Duddeck D, editor. Heidelberg: Hüthig, pp. 280–284.

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