title: Designing Real-time Decision Support for Trauma Resuscitations.
abstract: BACKGROUND
  Use of electronic clinical decision support (eCDS) has been recommended to improve implementation of clinical decision rules. Many eCDS tools, however, are designed and implemented without taking into account the context in which clinical work is performed. Implementation of the pediatric traumatic brain injury (TBI) clinical decision rule at one Level I pediatric emergency department includes an electronic questionnaire triggered when ordering a head computed tomography using computerized physician order entry (CPOE). Providers use this CPOE tool in less than 20% of trauma resuscitation cases. A human factors engineering approach could identify the implementation barriers that are limiting the use of this tool.
  
  
  OBJECTIVE
  The objective was to design a pediatric TBI eCDS tool for trauma resuscitation using a human factors approach. The hypothesis was that clinical experts will rate a usability-enhanced eCDS tool better than the existing CPOE tool for user interface design and suitability for clinical use.
  
  
  METHODS
  This mixed-methods study followed usability evaluation principles. Pediatric emergency physicians were surveyed to identify barriers to using the existing eCDS tool. Using standard trauma resuscitation protocols, a hierarchical task analysis of pediatric TBI evaluation was developed. Five clinical experts, all board-certified pediatric emergency medicine faculty members, then iteratively modified the hierarchical task analysis until reaching consensus. The software team developed a prototype eCDS display using the hierarchical task analysis. Three human factors engineers provided feedback on the prototype through a heuristic evaluation, and the software team refined the eCDS tool using a rapid prototyping process. The eCDS tool then underwent iterative usability evaluations by the five clinical experts using video review of 50 trauma resuscitation cases. A final eCDS tool was created based on their feedback, with content analysis of the evaluations performed to ensure all concerns were identified and addressed.
  
  
  RESULTS
  Among 26 EPs (76% response rate), the main barriers to using the existing tool were that the information displayed is redundant and does not fit clinical workflow. After the prototype eCDS tool was developed based on the trauma resuscitation hierarchical task analysis, the human factors engineers rated it to be better than the CPOE tool for nine of 10 standard user interface design heuristics on a three-point scale. The eCDS tool was also rated better for clinical use on the same scale, in 84% of 50 expert-video pairs, and was rated equivalent in the remainder. Clinical experts also rated barriers to use of the eCDS tool as being low.
  
  
  CONCLUSIONS
  An eCDS tool for diagnostic imaging designed using human factors engineering methods has improved perceived usability among pediatric emergency physicians.
authors: Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, CA.
authors: Kabir
authors: K
authors: Yadav
authors: Division of Emergency Medicine, Children's National Medical Center, Washington, DC.
authors: James M
authors: JM
authors: Chamberlain
authors: Healthcare Safety Strategies, LLC, Blacksburg, VA.
authors: Vicki R
authors: VR
authors: Lewis
authors: MedStar Institute for Innovation, National Center for Human Factors in Healthcare, Washington, DC.
authors: Natalie
authors: N
authors: Abts
authors: George Washington University School of Medicine and Health Sciences, Washington, DC.
authors: Shawn
authors: S
authors: Chawla
authors: Design Interactive, Oviedo, FL.
authors: Angie
authors: A
authors: Hernandez
authors: Drexel University College of Medicine, Philadelphia, PA.
authors: Justin
authors: J
authors: Johnson
authors: Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC.
authors: Genevieve
authors: G
authors: Tuveson
authors: Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC.
authors: Randall S
authors: RS
authors: Burd
mesh_terms: D001930:Brain Injuries / Q000000981:diagnostic imaging* / Q000628:therapy*; D002675:Child, Preschool; D020000:Decision Support Systems, Clinical; D004636:Emergency Service, Hospital; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D012151:Resuscitation / Q000379:methods*; D012985:Software Design; D013997:Time Factors; D014057:Tomography, X-Ray Computed