CHIME Tom Seabury 31/02/2008

Research Proposal
This research aims to detail the barriers arising from reliance on existing user interface controls on the entry and rendition of codified fragments of EHR records where SNOMED CT is the reference terminology. This is in the context of a clinical user constituency who, for clinical expression on EHR screens have a variety of mental models & preferences, and where the information model is expressed in OpenEHR archetypes and templates. As well as evaluation of the constraints relating to user interface tooling, findings about the mental models and preferred means of expression amongst the clinical users will also be evaluated. The research proposal if for a Gap analysis between the capabilities of a representative set of actual User Interface tooling compared to the challenges these are expected to support; the satisfactory preparation of records which conform to an unambiguous clinical meaning when in the hands of competent clinical users, who themselves have divergent [mental models of the data needs and uses] There is an opportunity to conduct this research in conjunction with and supporting an EHR development initiative which is planned for a North London Heart Failure community of practise.

Introduction
For the clinical aspects of an EPR distinction has been drawn between the model of use, and the model of meaning [ref Rector] [expand] in which the model of use relates to the expected behaviour of interfaces the input and rendition of data. The model of meaning supports an abstract representation which maintains the semantic meaning. An idealised information chain would start form the clinical users conceptual model of what they wish to express, supported [not subverted] by the user interface model of how they may express that, in turn supported by the information model and reference terminology so that when later represented back to them it is both semantically intact, and presented in agreeable ways.

Rationale for the study

This research can contribute to or augment the ongoing work within NHS CfH to find pragmatic approaches to design for extant EHR products, and to guide design patterns for existing interface elements. This area has no strong evidence base from which to support assertions on design approaches.

Existing and related research

The existing literature in this area includes reports of the NHS pilot use of OpenEHR tools and methods, the deliberations of the NHS CfH Technical Office, some of which is in the public domain, or available to support this research.

The NHS Common User Interface programme has set out in an array of documents some of the interface propositions, designed to augment existing interface elements such as list boxes which wrap long text descriptions in standardised ways. These CUI outputs are derived from their own unpublished research.

Artefacts which may be used in research

The design outputs from work in the NMEpFIT geographic area will illustrate some of the mental models which exist. This work is available from the NHS Clinical Models collaborative website. Expert review of design templates to synthesise out the distinct mental models in use.

Methods
The research will be carried out integral to the development of a new clinical capability for an established HER. This EHR is already in clinical use as part of related research venture between CHIME at UCL and the Wittington NHS Trust. The associated infrastructure forms a strong basis for this research, including established relationships, trust and protocols, and an established computing platform. Together these allow greater focus on the research questions than the ancillary challenges. Prevalence of interface tool types. The evaluation of the user interface elements available in an anonymised sample of extant EHR systems will use a focussed survey, from which thematic identification will be performed, the initial analysis will be subject to expert review to confirm and refine the themes. Experts view will be sought of the impacts and possible amelioration of the tools mix available in each surveyed EHR. User Mental Models During the stage of gathering user expressed requirements an evaluation will be made of users mental models for a set of key clinical expression patterns. These will be compared against a prepared set of expected patterns, including those used in the SNOMED CT meta-model. The key patterns will be selected from those set out in the (yet to be published) NHS Common User Interface guidance on clinical noting. Examples of these mental models include the ways to express certainty, or to express absence. Attitude survey The clinical contributors to the designs will be surveyed for their attitudes to adopting different models of expression than their initial proposition. This will take the form of structured interviews. This will happen as part of presenting synthesised designs back to them, synthesised for conformance to SMOMED CT methods of expression i.e. maximally aligned to the reference terminology. The prevalence of user interface controls, grouped into recognisable behaviours is assessed by a review of EHR products, this will be an opportunist survey, not a structured market survey. However a set of product types will be set out and representatives from each type included in the survey. find the propensity of design contributors to accept the synthesis of their initial draft into one which is.I

Content models will be expressed in EN13606 compliant archetypes and templates, with SNOMED CT bound to these where deemed appropriate. These designs must be suitable for deployment within the established target EHR system.

Methods : Survey of User Interface tools

UI Toolkit sample audit [forms design alone?] There will need to be a tool capability audit for a range of clinical systems showing what tools are at the disposal of system designers, [whether or not they are actually used] [this must include any capabilily to combine controls with procedural code, to use procedural code to make multiple controls act as a unit such expression of qualifiers to a focus concept . Explain. NB Markwell point about expression in archetypes as a set of qualifiers in differing slots rather than in the single slot as a Ref Terminology expression]

Discussion
The boundary for and elements of an EHR system is variable and to an extent subjective based on design choices. The academic work of Weed [refs ] and Rector [refs] on the foundations of an Electronic Healthcare Record [EHR] up to the mid 1990s set out a model which remains substantially intact [i.e. not strongly disputed]. Rector et al stated the EHR should support an authentic account of the clinicians understanding, and not force clinicians to formulate statements in ways which they find unnatural [Rector et al 1991 Ref 1]. There are different models of how healthcare records are structured. Some of the differences arise from the difference in intension, so the model for HL7 its RIM differs from the Concept Model of SNOMED CT, and it is unlikely either of these are fully conincidental with the mental models of health and healthcare held by any single clinician. The HL7 model is focussed on transmission of messages, the SNOMED CT concept model is focussed on expression of fragments of clinical meaning, and the clinician has a model which spans clinical processes such as diagnosis and care planning, as well as an internalised knowledge of health, anatomy and medicine. The fact that the mental model of any once clinician is unlikely to include model in which the content of the EHR record is expressed leads to the challenge of interfacing with the clinician in ways that satisfy both their mental model, and the model in which the record is expressed [is the record expressed in a model?]. The transition from a thought held by the clinician to a statement in an EHR is a multiple step process, and for the purposes of this paper, one in which many of the intermediate steps are considered incidental, the focus of the study is the capability of the application interface tooling to satisfy the transition from mental models of clinical users to expression of these ideas in the reference clinical terminology. Rector in 2001 attests just how great is the
gulf in understanding between software developers and clinicians in both directions and that experience from collaboration on the Pen&Pad project reinforced that A successful system will have to cope with a range of tastes and ways of working [Rector 2001 Ref 2]

In order to lodge this work in the realm of current challenges and practise the reference clinical terminology will be SNOMED CT. This is the challenge SNOMED CT as the target reference terminology is a compositional system, which also has a quantity of prepared terms for back compatibility to pre-existing

terminologies. The correct balance between pre and post-coordination is relevant to the focus of this study and is discussed McKnight 1999 [Ref 3]Others too [Refs]

Related fields
Text or voice parsing for thematic identification .. Hobbs 2002 Happe 2003 [Refs]

Interface Terminologies
Interface Terminologies are proposed as a category to differentiate terminology systems optimised for use at the clinician interface, rather than optimised for retrieval speed, or for machine processing. Considering the propositions of Rosenbloom et al 2006 [Ref 4] calling for quantified evaluations of clinical usability which separately addresses factors ascribed to an interface terminology from those ascribed to the user interface tools . This separation appears to be based on the assumption that usability constraints inherent in the underlying pairing between the reference terminology with the user interface are either manifest as issues of the interface terminology, or have been eliminated exactly by the introduction of the interface terminology. This research seeks to analyse the [usability aspects] which emanate from the user interface tools, and the reference terminology, and as such it assumes that an interface terminology may or may not be deployed, but that the fundamental challenge is to describe the interface challenges which remain unsolved given the use of SNOMED CT as the reference terminology. the introduction of the usabil SNOMED CT fitness as the interface terminology SNOMED CT coverage Terminology Services to assist the interface design Addition of assertional knowledge as part of enhancing reference terminology into an interface terminology

Measures
Extent to which the model of meaning may be expressed through a user interface which uses current UI tools, and conforms to user expectations for entry, rather than retrieval. The Gap analysis will express a set of types of problem for which new UI requirements are indicated, effectively a list.

Rationale for method

The Design considerations

It is recognised that there are three related research themes to this proposal, the suitability of interface controls to the stated task, the prevalence of the sufficiency or insufficiency, and the propensity of clinicians to adopt rational but different information models. This set of research topics may prove too many and the possibility of restriction to just two of these is acknowledged. As there are existing infrastructure, and relationships from previous EHR design collaboration between UCL and Wittington, so the likelihood of data being available is good, Getting access to clinicians time is most likely if there is a credible and short lead time outcome, such as the initial usable design for a fragment of an EHR. Biases TBD Ethics As there is a reliance on clinicians to contribute to design, and as subject of surveys then there will need to be ethical approval gained. The commercial aspects of reviewing and classifying user interface behaviours and tooling [should be without issue]

Appendix X
User Interface Controls Radio Buttons Group Exclusive single response NB Neilsons guidance Always offer a default selection for radio button lists. By definition, radio buttons always have exactly one option selected, and you therefore shouldn't display them without a default selection. (Checkboxes, in contrast, often default to having none of the options selected.) [Ref 5] [[ this brings a set of problems about the need to express the negative, or reject the classification offered, etc. ]]. Single Selection Multiple Selection

Check Boxes List Box List Box Non-Parametric String Searches Text entry box Text entry box Text entry box Text entry box Tabbed Entry Iconic

Multiple responses possible Prepared values set values only Prepared values set values only Validated against reference content Validated against reference content Validated by data type alone Parsed for any recognised string sequences

Single Statement Multiple Statements

Any number including zero

Use of single icon to represent single concept or action

Coordinated controls AKA interaction

elements [Ref 6] Parametric String Searches i.e. some restriction placed on the set to be searched, say presetting the top level hierarchy Interaction elements

Linked Conditional Content Linked Conditional Content Data Entry grid Combos in a grid 1

Linear Non-Linear

Tabular Data Entry Rotational Gauges Handwriting interfaces Pen based GUI for PDAs Paper forms emulation Lists with sort and filter options, Edit in situ. Hyperlinks Grouped responses such as common combinations to populate a range of controls concurrently, allowing subsequent adjustment. Sliders Voice interface Tabs Tree interface Modal and other Pop-ups Pie Menu, such as for laterality
1

Such as for Chem path Orders

Such as to move up the isa tree

Single Select Multiple Select

http://www.infragistics.com/dotnet/netadvantage/aspnet/webcombo.aspx#Overview

Appending further text to a selection, such as -L to indicate Left Iconography Readback of selections already made e.g. to show what term will be stored. Augmentation by use of context menus e.g. within a control holding a procedure name, the laterality could be selected by a right click? Winnowing AKA "Refine Results."

Sections without an obvious place as yet: Semiotics; includes the study of how meaning is constructed and understood. Forms Vs Applications A distinction between electronic forms, and applications has been defined by Nielsen as the inclusion of programmable logic and workflow in applications [Ref 7]. From a commercial point of view there is a distinction too, that configuration of form is often delegated to the user community where they are given tools for such interface generation, whereas programme logic and workflow require a greater quantity of rigorous preparation and testing, frequently described as engineering and leading to greater cost and development lead times. In Neilsens testing of 46 Web-based applications, one of the most serious problems was users' lack of up-front understanding of each application's task structure and basic goals. Risks There are risks from overlap with other work being prepared in this area such as the NHS Common User Interface Programme There are risks from any strong dependency on the EHR implementation at the Whittington NHS Trust There are risks associated with getting adequate access to the nascent EHR user community.

Rector, A.L.; Nowlan, W.A. & Kay, S. (1991), 'Foundations for an electronic medical record.', Methods Inf Med 30(3), 179--186.
2

Rector, A. (2001), 'AIM: a personal view of where I have been and where we might be going.', Artif Intell Med 23(1), 111--127.
3

McKnight, L.K.; Elkin, P.L.; Ogren, P.V. & Chute, C.G. (1999), 'Barriers to the clinical implementation of compositionality.', Proc AMIA Symp, 320--324.
4

Rosenbloom, S.T.; Miller, R.A.; Johnson, K.B.; Elkin, P.L. & Brown, S.H. (2008), 'A Model for Evaluating Interface Terminologies.', J Am Med Inform Assoc 15(1), 65--76.
5

Jakob Nielsen's Alertbox, September 27, 2004: Checkboxes vs. Radio Buttons. http://www.useit.com/alertbox/20040927.html viewed 28/12/2007
6

interaction elements (e.g., groups of radio buttons, Jakob Nielsen's Alertbox, September 19, 2005: http://www.useit.com/alertbox/forms.html viewed 28/12/2007
7

Jakob Nielsen's Alertbox, September 19, 2005: Forms vs. Applications. http://www.useit.com/alertbox/forms.html viewed 28/12/2007