title: The ALFA (Activity Log Files Aggregation) toolkit: a method for precise observation of the consultation.
abstract: BACKGROUND
  There is a lack of tools to evaluate and compare Electronic patient record (EPR) systems to inform a rational choice or development agenda.
  
  
  OBJECTIVE
  To develop a tool kit to measure the impact of different EPR system features on the consultation.
  
  
  METHODS
  We first developed a specification to overcome the limitations of existing methods. We divided this into work packages: (1) developing a method to display multichannel video of the consultation; (2) code and measure activities, including computer use and verbal interactions; (3) automate the capture of nonverbal interactions; (4) aggregate multiple observations into a single navigable output; and (5) produce an output interpretable by software developers. We piloted this method by filming live consultations (n = 22) by 4 general practitioners (GPs) using different EPR systems. We compared the time taken and variations during coded data entry, prescribing, and blood pressure (BP) recording. We used nonparametric tests to make statistical comparisons. We contrasted methods of BP recording using Unified Modeling Language (UML) sequence diagrams.
  
  
  RESULTS
  We found that 4 channels of video were optimal. We identified an existing application for manual coding of video output. We developed in-house tools for capturing use of keyboard and mouse and to time stamp speech. The transcript is then typed within this time stamp. Although we managed to capture body language using pattern recognition software, we were unable to use this data quantitatively. We loaded these observational outputs into our aggregation tool, which allows simultaneous navigation and viewing of multiple files. This also creates a single exportable file in XML format, which we used to develop UML sequence diagrams. In our pilot, the GP using the EMIS LV (Egton Medical Information Systems Limited, Leeds, UK) system took the longest time to code data (mean 11.5 s, 95% CI 8.7-14.2). Nonparametric comparison of EMIS LV with the other systems showed a significant difference, with EMIS PCS (Egton Medical Information Systems Limited, Leeds, UK) (P = .007), iSoft Synergy (iSOFT, Banbury, UK) (P = .014), and INPS Vision (INPS, London, UK) (P = .006) facilitating faster coding. In contrast, prescribing was fastest with EMIS LV (mean 23.7 s, 95% CI 20.5-26.8), but nonparametric comparison showed no statistically significant difference. UML sequence diagrams showed that the simplest BP recording interface was not the easiest to use, as users spent longer navigating or looking up previous blood pressures separately. Complex interfaces with free-text boxes left clinicians unsure of what to add.
  
  
  CONCLUSIONS
  The ALFA method allows the precise observation of the clinical consultation. It enables rigorous comparison of core elements of EPR systems. Pilot data suggests its capacity to demonstrate differences between systems. Its outputs could provide the evidence base for making more objective choices between systems.
authors.affiliation: Biomedical Informatics, Division of Community Health Sciences, St. George's University of London, London SW17 0RE, UK. slusigna@sgul.ac.uk
authors.forename: Simon
authors.initials: S
authors.lastname: de Lusignan
authors.forename: Pushpa
authors.initials: P
authors.lastname: Kumarapeli
authors.forename: Tom
authors.initials: T
authors.lastname: Chan
authors.forename: Bernhard
authors.initials: B
authors.lastname: Pflug
authors.forename: Jeremy
authors.initials: J
authors.lastname: van Vlymen
authors.forename: Beryl
authors.initials: B
authors.lastname: Jones
authors.forename: George K
authors.initials: GK
authors.lastname: Freeman
mesh_terms: D001292:Attitude to Computers; D003201:Computers; D005194:Family Practice; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000458:organization & administration*; D011381:Programming Languages; D012017:Referral and Consultation / Q000458:organization & administration*; D012680:Sensitivity and Specificity; D012984:Software; D014584:User-Computer Interface