title: Usability Testing of a Complex Clinical Decision Support Tool in the Emergency Department: Lessons Learned.
abstract: BACKGROUND
  As the electronic health record (EHR) becomes the preferred documentation tool across medical practices, health care organizations are pushing for clinical decision support systems (CDSS) to help bring clinical decision support (CDS) tools to the forefront of patient-physician interactions. A CDSS is integrated into the EHR and allows physicians to easily utilize CDS tools. However, often CDSS are integrated into the EHR without an initial phase of usability testing, resulting in poor adoption rates. Usability testing is important because it evaluates a CDSS by testing it on actual users. This paper outlines the usability phase of a study, which will test the impact of integration of the Wells CDSS for pulmonary embolism (PE) diagnosis into a large urban emergency department, where workflow is often chaotic and high stakes decisions are frequently made. We hypothesize that conducting usability testing prior to integration of the Wells score into an emergency room EHR will result in increased adoption rates by physicians.
  
  
  OBJECTIVE
  The objective of the study was to conduct usability testing for the integration of the Wells clinical prediction rule into a tertiary care center's emergency department EHR.
  
  
  METHODS
  We conducted usability testing of a CDS tool in the emergency department EHR. The CDS tool consisted of the Wells rule for PE in the form of a calculator and was triggered off computed tomography (CT) orders or patients' chief complaint. The study was conducted at a tertiary hospital in Queens, New York. There were seven residents that were recruited and participated in two phases of usability testing. The usability testing employed a "think aloud" method and "near-live" clinical simulation, where care providers interacted with standardized patients enacting a clinical scenario. Both phases were audiotaped, video-taped, and had screen-capture software activated for onscreen recordings.
  
  
  RESULTS
  Phase I: Data from the "think-aloud" phase of the study showed an overall positive outlook on the Wells tool in assessing a patient for a PE diagnosis. Subjects described the tool as "well-organized" and "better than clinical judgment". Changes were made to improve tool placement into the EHR to make it optimal for decision-making, auto-populating boxes, and minimizing click fatigue. Phase II: After incorporating the changes noted in Phase 1, the participants noted tool improvements. There was less toggling between screens, they had all the clinical information required to complete the tool, and were able to complete the patient visit efficiently. However, an optimal location for triggering the tool remained controversial.
  
  
  CONCLUSIONS
  This study successfully combined "think-aloud" protocol analysis with "near-live" clinical simulations in a usability evaluation of a CDS tool that will be implemented into the emergency room environment. Both methods proved useful in the assessment of the CDS tool and allowed us to refine tool usability and workflow.
authors.affiliation: Hofstra North Shore-LIJ School of Medicine, Department of Medicine, Manhasset, NY, United States. apress@nshs.edu.
authors.forename: Anne
authors.identifier: http://orcid.org/0000-0001-5329-7715
authors.initials: A
authors.lastname: Press
authors.forename: Lauren
authors.identifier: http://orcid.org/0000-0002-0436-8094
authors.initials: L
authors.lastname: McCullagh
authors.forename: Sundas
authors.identifier: http://orcid.org/0000-0003-1153-6313
authors.initials: S
authors.lastname: Khan
authors.forename: Andy
authors.identifier: http://orcid.org/0000-0002-1510-2785
authors.initials: A
authors.lastname: Schachter
authors.forename: Salvatore
authors.identifier: http://orcid.org/0000-0003-2024-4216
authors.initials: S
authors.lastname: Pardo
authors.forename: Thomas
authors.identifier: http://orcid.org/0000-0003-1005-227X
authors.initials: T
authors.lastname: McGinn
keywords: Wells criteria; clinical decision support; clinical prediction rules; emergency department; pulmonary embolism; usability testing