Information system support as a critical success factor for chronic disease management: Necessary but not sufficient

This is a review for Green C, Fortin P, Maclure M, Macgregor A, Robinson S. for the article entitled Information system support as a critical success factor for chronic disease management: Necessary but not sufficient.

Research question

What are the critical success factors enabling the translation of clinical and operational knowledge about effective and efficient chronic care management into primary care practice?

Methods

A chronic disease management (CDM) collaborative of primary care physicians with documented improvement in adherence to clinical practice guidelines using a web-based patient registry system with CDM guideline-based flow sheet. Participants in this study were thirty community-based physician using predominantly paper records, plus a project management team including the physician lead, project manager, and support team. A critical success factor analysis was then performed to analyze necessary and sufficient pathways which could then be used to translate the knowledge into clinical practice.

Environment

Two separate qualitative studies that attempted to identify user task flows with an existing EMR, to better understand the environment in which these tasks are performed, and to determine how overall usability can be improved.

Design

This project was created as a prospective case study which noted aberrations. Positive deviants were identified using the following key feature sets:

• Key informant interviews

• Process observation

• Document review

Measurements

Each of the qualitative studies focused on users of the Longitudinal Medical Record, a web-based application that facilitates the management of patient information, provides clinical messaging, and standardizes methods of data entry and retrieval.

Results

Findings from both studies raised issues with the amount and organization of information in the display, interference with workflow patterns of primary care physicians, and the availability of visual cues and feedback. These findings were then used to recommend user interface design changes.

Main results

A web-based clinical decision management 'toolkit' was found to be a direct critical success factor that allowed this group of physicians to improve their practice by tracking patient care processes using evidence-based clinical practice guideline-based flow sheets. The information and communication technology 'factor' was sufficient for success only as part of a set of six direct critical success factor components:

• Health delivery system enhancements

• Organizational partnerships

• Funding mechanisms

• Project management

• Practice models

• Formal knowledge translation practices

Conclusion

Through a thorough examination of two studies, it can be shown that qualitative research can help focus attention on user tasks and goals and identify patterns of care. Findings from both studies found consistency with regards to issues with the organization of information in the display, interference with workflow patterns of primary care physicians, and the availability of visual cues.

Commentary

Usability engineering can play a valuable role in assisting product design teams, unfortunately it has not been a routine part of designing clinical computing systems. Upon interviewing many of the test subjects who evaluated the EMR system, some identified system speed to be the primary determinant of user satisfaction, but most felt that usability principles and not speed or technology alone was necessary for the success of the EMR. Although usability is a broad term, it can be narrowed to two groups via various theories of human cognition and visual sensory perception.

First, it relates to navigation and system content. This is where efficiency of the EMR comes into play in defining usability. When efficiency slows down, the physician blames system speed, however technology is not the issue, rather often its the myriad of details and popup menus which create an overload in visual sensation. The fact that often the users created workarounds by opening multiple browsers reinforced this conclusion. Navigation and system content needs to be designed around user workflow--not a one size fits all. Different practice styles from various specialties and personalities come into play.re is

Second, information design is an important aspect of usability. Cognitive load theory defines the amount of "mental energy" needed to process the information or task in front of the user. There is a direct relationship between cognitive load and the amount of information present. Visualization also affects cognitive load as when too many screen elements come close together, the processing of information becomes slowed. Resolution can decrease efficiency if contrast or colors are not ideal and can mask the visual hierarchy.

Related papers

• Another one of B. Middleton's papers: Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA