title: Implementation of a Computerized Screening Inventory: Improved Usability Through Iterative Testing and Modification.
abstract: BACKGROUND
  The administration of health screeners in a hospital setting has traditionally required (1) clinicians to ask questions and log answers, which can be time consuming and susceptible to error, or (2) patients to complete paper-and-pencil surveys, which require third-party entry of information into the electronic health record and can be vulnerable to error and misinterpretation. A highly promising method that avoids these limitations and bypasses third-party interpretation is direct entry via a computerized inventory.
  
  
  OBJECTIVE
  To (1) computerize medical and behavioral health screening for use in general medical settings, (2) optimize patient acceptability and feasibility through iterative usability testing and modification cycles, and (3) examine how age relates to usability.
  
  
  METHODS
  A computerized version of 15 screeners, including behavioral health screeners recommended by a National Institutes of Health Office of Behavioral and Social Sciences Research collaborative workgroup, was subjected to systematic usability testing and iterative modification. Consecutive adult, English-speaking patients seeking treatment in an urban emergency department were enrolled. Acceptability was defined as (1) the percentage of eligible patients who agreed to take the assessment (initiation rate) and (2) average satisfaction with the assessment (satisfaction rate). Feasibility was defined as the percentage of the screening items completed by those who initiated the assessment (completion rate). Chi-square tests, analyses of variance, and Pearson correlations were used to detect whether improvements in initiation, satisfaction, and completion rates were seen over time and to examine the relation between age and outcomes.
  
  
  RESULTS
  Of 2157 eligible patients approached, 1280 agreed to complete the screening (initiation rate=59.34%). Statistically significant increases were observed over time in satisfaction (F3,1061=3.35, P=.019) and completion rates (F3,1276=25.44, P<.001). Younger age was associated with greater initiation (initiated, mean [SD], 46.6 [18.7] years; declined: 53.0 [19.5] years, t2,155=-7.6, P<.001), higher completion (r=-.20, P<.001), and stronger satisfaction (r=-.23, P<.001).
  
  
  CONCLUSIONS
  In a rapid-paced emergency department with a heterogeneous patient population, 59.34% (1280/2157) of all eligible patients initiated the computerized screener with a completion rate reaching over 90%. Usability testing revealed several critical principles for maximizing usability of the computerized medical and behavioral health screeners used in this study. Further work is needed to identify usability issues pertaining to other screeners, racially and ethnically diverse patient groups, and different health care settings.
authors.affiliation: Departments of Emergency Medicine, Psychiatry, and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States. edwin.boudreaux@umassmed.edu.
authors.forename: Edwin D
authors.identifier: http://orcid.org/0000-0002-3223-6371
authors.initials: ED
authors.lastname: Boudreaux
authors.forename: Andrew Christopher
authors.identifier: http://orcid.org/0000-0002-7080-0949
authors.initials: AC
authors.lastname: Fischer
authors.forename: Brianna Lyn
authors.identifier: http://orcid.org/0000-0001-7757-422X
authors.initials: BL
authors.lastname: Haskins
authors.forename: Zubair
authors.identifier: http://orcid.org/0000-0003-2020-7861
authors.initials: Z
authors.lastname: Saeed Zafar
authors.forename: Guanling
authors.identifier: http://orcid.org/0000-0003-4796-3931
authors.initials: G
authors.lastname: Chen
authors.forename: Sneha A
authors.identifier: http://orcid.org/0000-0002-4946-1356
authors.initials: SA
authors.lastname: Chinai
keywords: behavioral medicine; computers; electronic health records; public health; screening; telemedicine