Multi-Inclusion, Universal Client Electronic Health Record€¦ · New GUI feature design sets for...

Quarterly Report: March 02, 2014 – June 01, 2014 of 12

Multi-Inclusion, Universal Client Electronic Health Record

Quarterly Report: March 02, 2014 – June 01, 2014

September 15th, 2014


Multi-Inclusion, Universal Client Electronic Health Record (W81XWH1120183): Quarterly Report (3/02/14 – 06/01/14) September 15th, 2014

Table of Contents

1. AWARD INFORMATION ...................................................................................................................... 3

2. CURRENT STAFF WITH PERCENTAGE EFFORT OF EACH ON PROJECT ................................................ 3

3. AWARD EXPENDITURES TO DATE ....................................................................................................... 3

4. COMMENTS ON ADMINISTRATIVE AND LOGISTICAL MATTERS ........................................................ 4

5. SCIENTIFIC PROGRESS ....................................................................................................................... 10

6. PLANS AND MILESTONES FOR NEXT QUARTER ................................................................................ 11



1. AWARD INFORMATION

Item Description

Award Number: W81XWH1120183

Report Date: September 15th, 2014

Reporting Period: March 02, 2014 – June 01, 2014

PI: Christopher Goranson | Jihoon Kang

Telephone Number: (212) 229-6825 x4712

Institution: Parsons Institute for Information Mapping, of The New School

Project Title: Multi-Inclusion, Universal Client Electronic Health Record

2. CURRENT STAFF WITH PERCENTAGE EFFORT OF EACH ON PROJECT

Staff Member Percentage

Goranson, Christopher 40%

Lim, GangHyuk (Andy) 100%

Kang, Jihoon 65%

Koshkakaryan, Marine 100%

Pedrini, Noah 100%

Weir, Scot 30%

Wanner, Katie 35%

Yi, Ann 100%

Note: percentage effort for each staff member represents the most recent month’s activities towards this project and are rounded to the closest number.

3. AWARD EXPENDITURES TO DATE

Item This Quarter Cumulative

Personnel $113,321.25 $439,305.50

Fringe Benefits $38,584.44 $151,691.81

Supplies $0 $308.70

Travel $0 $22,085.47

Equipment $0 -

Workshop/Conference Registration $0 $0

Other $130.16 $1,174.01

Subtotal $152,035.85 $614,565.49



Item This Quarter Cumulative

Indirect Costs $62,838.22 $261,036.55

Fee - -

Total $214,874.07 $875,602.04

4. COMMENTS ON ADMINISTRATIVE AND LOGISTICAL MATTERS Award Expenditures to Date Expenditures detailed above are for the period of March 2014 through May 2014. These numbers may be different from the official SF-272 report due to differing time periods. We have approximately $173,397.95 remaining on this award following this quarter. Milestones / Deliverables Following the No Cost Extension granted through a contract modification on April 22nd, 2013, we adjusted our milestones accordingly to account for the review and redesign of Essentris ED, conduct surveys to identify the values of the changes and to complete work towards the GUI design of the multi-inclusion, universal client electronic health record. Milestone Revised

Plan Date

FY10: Develop user experience and workflows for the GUI. 30-Jun-14 FY10: Revise/refine usability metrics and design heuristics. 11-Jun-13 FY10: GUI design/redesign iterations. 30-Jun-14 FY10: Outreach to MHS functional community for expert and end-user feedback. 30-Jun-14 FY10: Definition of mission and objectives with MHS, TATRC, and other stakeholders. 11-Mar-12 FY10: Develop initial GUI design for the multi-inclusion, universal client. 30-Jun-14 FY10: Identify initial usability metrics and design heuristics. 11-Mar-13 FY10: Prepare position paper / guidance document. 30-Jun-14 Expected current tasks identified under the first milestone, FY10: Develop user experience and workflows for GUI are identified in greater detail in the Project Task table below. Other milestones including FY10: Revise/refine usability metrics and design heuristics and FY10: GUI design/redesign iterations are considered elements of these tasks. The task breakdown below also lists new tasks that have become necessary in order to support the implementation of the identified design changes. This includes supporting the technical implementation of the design changes during Sprint 30 and a usability validation of the outcomes. These milestones will also incorporate new tasks that we believe complement the goals of the original ones; EMERALD (EHR Designer) being one of them. Through these and other developments we believe that this project continues to adapt well to the changing environment around health informatics and electronic medical records in the DoD. Assessing “usability” per the needs of the project stakeholders is also an important aspect of this project. We are evaluating our designs using measurable outcomes that document the effect that redesigned



modules have on improving Essentris and create a blueprint for design best practices amongst other EMRs. Project Task* Start Finish Status

FY10: Develop user experience and workflows for GUI 21-May-12 30-Jun-14 In Progress Groundwork Design and Style Guide 21-May-12 18-Jul-12 Complete Obtaining and evaluating Style Guide 21-May-12 21-May-12 Complete First iteration of PIIM’s GUI Style Guide 1-Jun-12 15-Jun-12 Complete Stakeholder Review 16-Jul-12 18-Jul-12 Complete Tracking Board 22-Jul-12 26-Jul-13 In Progress

Site visit: workflow/usage analysis, end-user interviews 29-Aug-12 30-Aug-12 Complete Feature/product analysis 13-Aug-12 9-Sep-12 Complete Gathering use cases and user requirements 13-Aug-12 9-Sep-12 Complete Heuristic evaluation 12-Sep-12 20-Sep-12 Complete Design recommendations 12-Sep-12 20-Sep-12 Complete Stakeholder review on design recommendations 2-Oct-12 4-Dec-12 Complete

Short-term GUI enhancement design set (low-hanging fruits) 4-Dec-12 18-Jan-12 Complete

Long-term GUI enhancement design set (high-hanging fruits) 4-Dec-12 18-Jan-12 Complete Support technical implementation (Sprint 32) 29-Apr-13 26-Oct-13 Complete Pre and post deployment GUI Revisions and Debugging1 14-Oct-13 12-Jan-14 Complete New GUI feature design sets for the Long-term GUI 16-Dec-13 28-Feb-14 Complete Usability validation2 29-Apr-13 ------------- In Progress

Notes 1-Oct-12 13-Dec-13 In Progress Site visit: workflow/usage analysis, end-user interviews 7-Nov-12 16-Nov-12 Complete Feature/product analysis 15-Oct-12 5-Nov-12 Complete Gathering use cases and user requirements 15-Oct-12 5-Nov-12 Complete Heuristic evaluation 18-Mar-13 20-Dec-13 Complete Design recommendations 18-Mar-13 20-Dec-13 Complete Stakeholder review on design recommendations 6-Jan-14 16-May-14 Complete Analysis of Rankings and Feedback from Stakeholders 19-May-14 27-Jun-14 Complete Short-term GUI enhancement design set (low-hanging fruits)3 ------------- ------------- Not started Long-term GUI enhancement design set (high-hanging fruits) ------------- ------------- Not started

Order Editor (OE) 18-Dec-12 7-Jun-13 In Progress Site visit: workflow/usage analysis, end-user interviews 18-Dec-12 11-Jan-13 Complete Feature/product analysis 11-Mar-13 22-Mar-13 Complete

Gathering use cases and user requirements 11-Mar-13 22-Mar-13 Complete

Heuristic evaluation, Design recommendations, GUI Design Set4 ------------- ------------- Not started FY10: Revise/refine usability metrics and design heuristics 1-Jul-12 12-Sep-12 In Progress Developing the usability evaluation method 1-Jul-12 10-Sep-12 Complete Staff training 11-Sep-12 12-Sep-12 Complete

1 Three new tasks were added to support Tracking Board: (1) supporting the implementation during Sprint 32; (2) revising the GUI before and after based on user feedback; and (3) designs for additional GUI / UX solutions for the long-term GUI Enhancement Set. These additional tasks were defined through the ED CAG and CDR Park. 2 The IRB protocol under review at Naval Medical Center San Diego. 3 Due to the length of stakeholder review, the GUI designs for the Notes module were delayed. 4 These tasks were delayed due to new tasks requested by the CAG group and longer than expected completion times for previous tasks.



IRB protocol development and submission 04-Jan-13 04-Jun-13 Complete The New School IRB Approval (Exempt Status) 04-Jun-13 04-Sep-13 Complete HRPO Approval (Exempt Status) 10-Sep-13 30-Sep-13 Complete NMCSD IRB development 14-Oct-13 28-May-14 Complete NMCSD IRB submittal 4-Jun-14 04-Jun-14 In Progress NMCSD IRB Approval (Exempt Status)5 4-Jun-14 ------------- In Progress FY10: iEHR Design Recommendation and Consultation 19-Mar-13 11-Jun-14 In Progress Presenting research/design outcomes the iEHR group6 19-Mar-13 5-Sep-14 Scheduled Releasing research and design documentation 19-Mar-13 31-July-14 Scheduled FY10: Development of EHR Designer7 Nov-22-13 30-Jun-14 In Progress Wireframes 01-Mar-14 30-Apr-14 Complete Style Guide and Final GUI 01-Apr-14 05-16-14 Complete System architecture 18-Dec-13 30-Apr-14 Complete Setup of infrastructure 18-Dec-13 30-Apr-14 Complete Documentation on wiki 24-Mar-14 30-Jun-14 Complete Feature/Requirements Analysis 22-Nov-13 31-Mar-14 Complete Define EHR components and elements libraries 01-Mar-14 30-Apr-14 Complete Database implementation 24-Mar-14 30-Apr-14 Complete Develop, Test (Phase 1) 01-Mar-14 27-Jun-14 In Progress Prototype release 27-Jun-14 31-Jul-14 In Progress

• Specific tasks are subject to change through the project’s progression. Flowsheets, Summary

Screens, Dashboards/Reports, Patient Control Screen, Web Links and P&P Format may be included as secondary, additional tasks as time permits.

• Some tasks have been taking more time than the estimated task duration shown in the original SOW due to the number of usability violations, stakeholders’ availability for reviews, and technical issues the Essentris testing server. The task schedules have been modified over the course of this project.

• EHR Designer schedule has been updated to reflect the actual start dates for the individual tasks and their estimated end dates.

• * Task removed, too specific for this list. We started with cataloging patient demographic and patient search screens instead of ED Tracking Board.

Initial Essentris-Specific Design Objectives: During the Essentris Clinical Content Design Session held in spring 2012, PIIM had the opportunity to meet with project stakeholders and identify a list of potential key EMR features to be redesigned based on feedback and user need: 1. ED Tracking Board (ED Tracking, Triage Tracking, Tracking Compact, Tracking VS, etc.) 2. Notes (DOD ED Medical Record, Edit and Review modes, usability, template selection) 3. Order Entry (New Order, Standard Order Set, Order States, workflow, data considerations) 5 The IRB protocol is under review at Naval Medical Center San Diego. 6 We will be presenting findings from this project at the 2014 Military Health System Research Symposium in August and 2014 OSEHRA Open Source EHR Summit in September. 7 We cataloged patient demographic and patient search screens instead of ED Tracking Board elements and rules, as that was too specific for the purposes of the EHR Designer. The high-level UX flowchart determined to be necessary given the design of the prototype and was removed.



4. Flow Sheets (Charted order results and imports, one time orders, continuous orders) 5. Summary Screens 6. Dashboards/Reports 7. Web Links (ED Reports, access to resources, CPOE Transcriptions Dashboard, CHCS

transcriptions) 8. Nuance (Dragon) Integration 9. Patient Banner Redesign 10. Bed Transfer Task Execution Steps 11. Other Items (policies and procedures, training materials, patient aftercare content capabilities,

imaging capabilities, choice lists, Database Items or DBIs) 12. Calculation Based Dosing Major design objectives are highlighted in bold in the list above. These tasks are high-value, high-intensity tasks, generally taking more time and client interaction than we anticipate for the other tasks. These tasks also tend to be “parent” tasks – once completed, other tasks will be easier to manage. To date, we have conducted four site visits to cover three major design objectives (ED Tracking Board, Notes, Order Entry) and anticipate completing the remaining major visit will occur once work has progressed further. A fourth (Flow Sheets) is also underway. We are establishing a pattern of support with ED Tracking Board that will be duplicated across the other major design objectives. The remaining tasks are viewed as somewhat smaller (e.g. Web Links, Patient Banner Redesign, etc.). Recent Activities During this quarter we have continued work on a number of supporting tasks:

1. PIIM worked with the CAG Working Group, staff at Naval Medical Center San Diego (NMCSD) and CliniComp to collect feedback on the usability violations and redesign recommendations (solutions) for the ED Medical Records Note module. PIIM has received feedback from reviewers of various user groups (e.g., physicians, NP, RN) who regularly work with ED Medical Records Note.

2. PIIM continued the EHR Designer effort and completed the first version of the interactive prototype. PIIM demonstrated the prototype to TATRC during Quarter 11.

3. PIIM is schedule to visit CliniComp Intl, San Diego, CA to discuss developments around the next-generation replacement for Essentris on June 24th.

4. PIIM will meet with BUMED members in San Diego to discuss future opportunities for collaboration and presenting outcomes from this project to various medical IT communities on June 24th.

5. PIIM supported the CAG group during Sprint 34. 6. PIIM continued to participate in the weekly ED CAG calls and as-needed by the working

group. We continue to review the EHR content materials provided by the team on Basecamp, and review feedback from the discussion boards.



The Electronic Health Record Designer On November 22n d , 2013 we proposed the development of a new project in order to further the design objectives of our “Develop initial GUI design for the multi-inclusion, universal client” milestone. After receiving feedback from our project stakeholders and others in the MHS community, we brainstormed a novel way to provide design best-practices and encourage greater usability in electronic medical records in a more interactive manner. That resulted in the initial ideas behind the proposal for a novel way to present design to programmers and medical practitioners alike. The Electronic Health Record Designer is a drag-and-drop, WYSIWYG EHR designer geared to both programmers and medical professionals. By taking advantage of design best-practices and utilizing common workflows, the EHR Designer provides a way for anyone to quickly mockup a stylized graphical user interface that can be exported in a variety of formats, either as a proof-of-concept or framework for an eventual presentation layer. Utilizing styles from HealthBoard, JANUS, and next-gen AHLTA, we hope to empower decision-makers to create interfaces that are more suited to their individual specialty or need. By providing developers, providers and patients a tool to design the look and feel of the interfaces they use in clinical settings, the project hopes to empower users to have a greater say in how these systems look and feel and promote a more equitable balance between form and function. The EHR Designer will attempt to address user experience issues by:

1. Giving users a web-based tool for laying out the framework of a custom EMR screen 2. Providing context-sensitive feedback that integrates design best practices 3. Adding social features that support building a community around the importance of good design

for medical systems

Image: Initial GUI mock-up for the EHR Designer (credit: Ann Yi)

A key feature of this project is the development of an immediate on-line resource. We are reaching out through the OSEHRA community and wiki to explore and solicit support from a broader user community, and will be presenting the tool at the next annual OSEHRA conference. During the last two quarters the



core functionality was implemented through a web-based prototype using current and forward-thinking development practices and technologies. The EHR Designer Engineering Volume includes detailed information on the implementation of the prototype and underlying technology. The cataloging research task captured how leading EHRs approach user interface design and interaction. This exercise, along with previous and other current PIIM research informed the EHR specific capabilities of this design tool. A significant portion of research conducted for the Essentris redesign project has been identified as having significant relevance to the EHR Designer project. The extensive archive of leading production EHR systems, collected for the purpose of compiling a visual reference of prevailing user interfaces, will be used to compile an exhaustive list of interface elements common to all EHR systems. Once completed, this list will drive the EHR Designer’s library of interface components that the user will be able to add to their design. The best practices and lessons learned from all previous work will help define the rules that will drive the context-sensitive design alerts. At a high-level, users of the EHR Designer will be able to design complex, nested views by dragging-and- dropping commonly-occurring interface elements and previewing them in real-time. The application will streamline the process of designing such a system for production use and encourage interfaces that are intuitive, standardized, and conformant to best practices. As changes are made, context-sensitive design alerts will appear (and disappear) based on the components at play and the property values they have been assigned. These alerts will communicate potential violations of design “best practices” and give suggestions for how closer compliance could be achieved. A significant portion of research conducted for the Essentris redesign project has been identified as having significant relevance to the EHR Designer project. The extensive archive of leading production EHR systems, collected for the purpose of compiling a visual reference of prevailing user interfaces, will be used to compile an exhaustive list of interface elements common to all EHR systems. This list will drive the EHR Designer’s library of interface components that the user will be able to add to their design. The best practices and lessons learned from all previous work will help define the rules that will drive the context-sensitive design alerts. The EHR Designer concept and prototype will be presented at the annual OSEHRA summit in September 2014. The code repository will be made public to the OSEHRA community in 2014. A demo version of the prototype is hosted by PIIM and available at http://ar210.piim.newschool.edu:3010. The EHR Designer and its Libraries have potential for ongoing growth through developer and user feedback and contribution. Following is a list of additional capabilities the team has identified as valuable if added to the core:

1. Add ability to apply design themes 2. Further FHIR incorporation 3. Support for light event handling and navigation 4. Export project, explore options other than pdf and html 5. Technology specific component libraries



6. Cloud hosting 7. Build out the social and sharing capabilities to include creating user groups for collaboration 8. Add user designed component libraries 9. Rules & Formulas 10. Testing and Deployment 11. Continue adding to the pre-designed components and template libraries based on outcomes

from the design and user experience team effort. 12. Make final adjustments based on final GUI design guidance for multi-inclusion, universal

client. Final Deployment IRB Protocol On September 30th, 2013 we received notification that the HRPO identified our research as an exempt activity, which cleared the way towards surveying users prior to and following the deployment of the design changes to the Essentris system. Shortly following the announcement, we contacted the four initial hospitals to request a review of the protocol prior to a formal site survey. With the exception of San Diego, we have not received guidance from the hospitals we contacted, but are now connected through CDR Park to staff who are assisting us in figuring out the best way to proceed with receiving a formal review from San Diego’s IRB. A key priority going into this quarter is to receive approval from San Diego, as this is the last remaining hurdle standing in our way to conducting a review of the Tracking Board changes that went into effect in December 2013. Concerns for Next Quarter IRB final sign-off is essential for our testing of the effectiveness of the design work. To date, we have received IRB approval from both The New School’s IRB and the DoD’s HRPO. We have submitted the IRB application to medical centers during this quarter. However, we have not received the approval for conducting the user survey. This is a substantial dependency; we cannot continue the process user acceptance validation without completing the user survey. Development of assets towards a universal GUI remain a priority – our progress in the following section describes some of our advancements towards that goal. 5. SCIENTIFIC PROGRESS This quarter and project continued to be busy as we have deployed the final version of Tracking Board.

ED Tracking Board GUI Design Sets Working with CDR Peter Park, Lisa Bartolo-Barnett, and CCI team, we continued to support the deployment of the LHF designs of the ED Tracking Board. There are 4 sites where PIIM’s Tracking Board has been deployed or is scheduled to be deployed: Naval Medical Center San Diego David Grant USAF Medical Center at Travis Air Force Base



Madigan Army Medical Center Walter Reed National Military Medical Center Bethesda We anticipate that PIIM’s Tracking Board will be used at additional sites.

ED Notes Heuristic Evaluation PIIM completed the heuristic evaluation on the ED Notes module in Quarter 10. In Quarter 11, PIIM recruited reviewers and distributed the evaluation report. We collected feedback from the reviewers and started organizing redesign recommendations by “Low-hanging,” “High-hanging,” or “Declined” following the identical methodology applied during the redesign iteration of ED Tracking Board. Supporting a Universal Client EHR PIIM continues to work on standardizing some of the guidance offered as part of this project for a broader audience. We continue to research on a number of existing EMR products to establish “best of breed” standards in design of common elements. It’s important to both our team and the project stakeholders to have access to existing models of handling notes, orders, tracking boards and other common (and not-so-common) modules. The evolution of these ideas has led us to the development of the EHR Designer. The EHR Designer During the last quarter the EHR Designer has been in active development. The development team uses JIRA to create sprints, report and track issues as the code is reviewed and the functionality is tested. Among many other features, the EHR Designer now has a library of basic HTML elements that can be dragged onto the canvas, and more importantly a library that provides a place for pre-designed EHR components. FHIR has been incorporated to allow the mapping of elements to the resources they will display and collect. The Engineering Volume provides in greater detail all of the functionality being developed and the technology used. 6. PLANS AND MILESTONES FOR NEXT QUARTER For the next quarter we have a number of items we will need to address, including:

1. PIIM will obtain the approval from the IRB of the medical centers to start the user acceptance validation survey for ED Tracking Board.

2. PIIM will begin the user survey on the recently deployed Tracking Board. 3. Following the final heuristic review, PIIM will begin developing high-level design concept for

the LHF and HHF GUI design sets for the ED Notes.

4. PIIM will continue supporting the new, deployed Tracking Board at EDs where implemented. 5. PIIM will work with CCI and CAG to deploy the HHF Tracking Board through the new version

of Essentris, contingent on support by CCI.



6. Support new deployed changes to additional modules where identified and scheduled by the CAG Working Group and CCI.

7. PIIM will continue building the EHR Designer and further develop tasks related to this effort.

8. Begin writing research paper for submission to peer-reviewed journal. 9. PIIM will present research and design outcomes from this project to health IT conferences.

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