title: Usability Testing and Adaptation of the Pediatric Cardiovascular Risk Reduction Clinical Decision Support Tool.
abstract: BACKGROUND
  Cardiovascular disease (CVD) is 1 of the leading causes of death, years of life lost, and disability-adjusted years of life lost worldwide. CVD prevention for children and teens is needed, as CVD risk factors and behaviors beginning in youth contribute to CVD development. In 2012, the National Heart, Lung, and Blood Institute released their "Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents" for clinicians, describing CVD risk factors they should address with patients at primary care preventative visits. However, uptake of new guidelines is slow. Clinical decision support (CDS) tools can improve guideline uptake. In this paper, we describe our process of testing and adapting a CDS tool to help clinicians evaluate patient risk, recommend behaviors to prevent development of risk, and complete complex calculations to determine appropriate interventions as recommended by the guidelines, using a user-centered design approach.
  
  
  OBJECTIVE
  The objective of the study was to assess the usability of a pediatric CVD risk factor tool by clinicians.
  
  
  METHODS
  The tool was tested using one-on-one in-person testing and a "think aloud" approach with 5 clinicians and by using the tool in clinical practice along with formal usability metrics with 14 pediatricians. Thematic analysis of the data from the in-person testing and clinical practice testing identified suggestions for change in 3 major areas: user experience, content refinement, and technical deployment. Descriptive statistical techniques were employed to summarize users' overall experience with the tool.
  
  
  RESULTS
  Data from testers showed that general reactions toward the CDS tool were positive. Clinical practice testers suggested revisions to make the application more user-friendly, especially for clinicians using the application on the iPhone, and called for refining recommendations to be more succinct and better tailored to the patient. Tester feedback was incorporated into the design when feasible, including streamlining data entry during clinical visits, reducing the volume of results displayed, and highlighting critical results.
  
  
  CONCLUSIONS
  This study found support for the usability of our pediatric CVD risk factor tool. Insights shared about this tool may be applicable for designing other mHealth applications and CDS tools. The usability of decision support tools in clinical practice depends critically on receiving (ie, through an accessible device) and adapting the tool to meet the needs of clinicians in the practice setting.
authors.affiliation: RTI International, Social Policy, Health and Economics Research Unit, Research Triangle Park, NC, United States. pamwilliams@rti.org.
authors.forename: Pamela A
authors.identifier: http://orcid.org/0000-0002-6040-6972
authors.initials: PA
authors.lastname: Williams
authors.forename: Robert D
authors.identifier: http://orcid.org/0000-0002-3803-1879
authors.initials: RD
authors.lastname: Furberg
authors.forename: Jacqueline E
authors.identifier: http://orcid.org/0000-0002-2210-8843
authors.initials: JE
authors.lastname: Bagwell
authors.forename: Kenneth A
authors.identifier: http://orcid.org/0000-0001-9040-1956
authors.initials: KA
authors.lastname: LaBresh
keywords: adaptation; cardiovascular diseases; clinical decision support; decision aids; guidelines; mHealth; pediatrics; risk factors; usability