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EHR Design Talk with Dr. Rick 12/3/12

December 3, 2012 Rick Weinhaus 6 Comments

The Snapshot-in-Time Design

There are two basic EHR designs for presenting the patient information that accumulates over time (see my last post).

By far, the most common EHR design solution is to display a summary screen of the patient’s current health information, organized by category (Problem List, Past Medical History, Medications, and so forth). Past information is available in date-sorted lists or indicated by start and stop dates.

The other design solution is to display a series of snapshots that capture the state of the patient’s health at successive points in time. While this design was at the core of paper-based charting (see Why T-Sheets Work), it is an uncommon EHR design.

In my opinion, the snapshot-in-time design has three advantages:

  • It supports our notion of causality – we see how earlier events affect subsequent ones.
  • The patient’s story is presented as a narrative that gradually unfolds. Humans excel at using narrative to organize and make sense of complex data.
  • Perhaps most importantly, a series of visual snapshots allows us to makes sense of abstract data by organizing it in visual space.

The following EHR screen mockups display a patient’s story as snapshots in time. While these illustrations are for an ambulatory EHR, the design works equally well for hospital-based systems.

To see the mockups, click on the PowerPoint link below. Once PowerPoint is open, expand the view by clicking on the full screen button in the lower right corner (indicated by arrow).

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Rick Weinhaus MD practices clinical ophthalmology in the Boston area. He trained at Harvard Medical School, The Massachusetts Eye and Ear Infirmary, and the Neuroscience Unit of the Schepens Eye Research Institute. He writes on how to design simple, powerful, elegant user interfaces for electronic health records (EHRs) by applying our understanding of human perception and cognition. He welcomes your comments and thoughts on this post and on EHR usability issues. E-mail Dr. Rick.

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6 Responses to “EHR Design Talk with Dr. Rick 12/3/12”

  1. 1
    Kyle Says:

    Dr Weinhaus

    In your design, wouldn’t it be worthwhile to include an ‘all dates’ option in the date picker so that you can get the best of both worlds in terms of accomdoating both fundament designs that you indicated

  2. 2
    A. Scarlat MD Says:

    Edward Tufte, considered by many as The Data Visualization Guru had patented years ago a UI for summarizing patient data:

    http://www.edwardtufte.com/bboard/q-and-a-fetch-msg?msg_id=0003mm

    I think it is relevant to anyone in the EHR UI domain.

  3. 3
    Myrtle Says:

    Dr. Rick, this is an outstanding UI design! Granted, I’m not a physician, but as technical writer I was able to appreciate the effective presentation of data, and your clear explanation as we progressed through the slides. I was also able to quickly see how the patient’s story unfolds, thanks to your great UI design.

  4. 4
    Rick Weinhaus, MD Says:

    Kyle, A. Scarlat MD, and Myrtle –

    Thanks so much for your comments.

    Kyle – You wrote, “wouldn’t it be worthwhile to include an ‘all dates’ option in the date picker so that you can get the best of both worlds . . .”

    I think that you’re right. If I understand you correctly, in the Problem List (for instance) you’d like to see not just the current list of problems but also the inactive and resolved ones with their start and end dates.

    It makes a lot of sense to provide that information. It could be accessed by expanding the Problem List pane, or even as the primary view. Similarly, instead of just displaying the current list of medications, as I understand it, you’re suggesting also providing information on discontinued ones including start and stop dates. Is this correct? Again, it would be fine to do this.

    My main point is that the commonly used EHR design (that I will present in my next post) requires a lot of cognitive effort. With that design, it’s virtually impossible to do something as simple as go back to a past date and reconstruct what glaucoma medications a patient was supposed to be taking at that time, let alone whether they were actually being taken.

    Alex – As I’m sure you would imagine, I am a huge fan of Edward Tufte and keep coming back both to his books and his posts.

    One of my favorite quotes of his is “. . . the overwhelming truth is that much of the history of progress in science and in communication can be written in terms of improvements in resolution.”

    I general, I like his sparkline design very much. That being said, I find his EHR design (see Figure 2 of the Lancet article you link to) to be almost the opposite of a snapshot-in-time design. Namely, it’s virtually impossible to get a sense of how all the disparate quantitative data elements fit together at any single point in time. For that, I think a multi-Y graph with the X-axis representing time works better.

    Also, I would have preferred to see the sequence of clinical events presented on the same (horizontal) time axis as the quantitative measures, as opposed to being displayed in the (vertical) column on the right side of the page. This would help minimize the need for presenting time and date information numerically (e.g., 1100 4.3.93), because a rough sense of the dates and times could be gotten from the timeline (X-axis) itself.

    Of course, this design is 20 years old and most of the interactive GUI patterns that we take for granted today just weren’t available then. EHR interaction design is still a very new field.

    Myrtle – Thanks so much! I look forward to your thoughts on how this design compares to the more common EHR design that I will present in my next post.

  5. 5
    Susan Crayne Says:

    I am not a physician but do write consumer-focused health software. I think it would be useful to have a view of a particular illness, together with treatments for that illness, through time — treatments to include medications. That would make it clear which treatments were effective. Such a view would be especially helpful for conditions like asthma, where many different medications are often tried over time.

  6. 6
    Rick Weinhaus, MD Says:

    Susan –

    Thanks so much for your comment! I believe that it’s at the crux of the issue – how to present longitudinal data so that it makes sense to the physician and patient and can be used to inform decision making going forward.

    In order for me and other readers to reply to your comment, it would be helpful if you could elaborate on what you’re suggesting.

    I assume that you’re not suggesting that the physician create a narrative text summary for a particular illness, but rather that data fields from multiple previous encounters be brought together and displayed as one or more screen views. Is this correct?

    If so, what would the screen view or views look like? Are you suggesting, for the diagnosis of asthma for instance, that the assessment and plan portions of previous visits be brought together as a date-sorted list or table?

    How would treatments, including medications, be displayed? Would they be displayed as other columns in that same date-sorted table, or would they be displayed as a separate list or table?

    Alternatively, are you suggesting that a series of snapshot-in-time be kept as the high-level visual design, but with data fields and data elements relevant to asthma highlighted or otherwise emphasized visually?

    Looking forward to your input,

    Rick

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