dashboard

Dashboards - Quality Performance at the Point of Care

I used to get quality reports once a year, then once a quarter. They were long, opaque, boring, and too detailed to digest. I was usually looking at them when I was too tired (at the end of a long day) and away from the battlefield. As a result, nothing much changed.

So, our team decided to provide "just in time" quality feedback to physicians at the point of care, and only for diabetes, and only for 8 quality indicators (there are dozens competing for my attention). The hope was that by giving feedback as the physician was about to see the patient, then she could take action and address the issues of concern. Here's what we built:

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Fig 1. Diabetes Dashboard

Here's a closer view of just the bottom of the dashboard showing the Quality Performance Indicators (back then, the Medicare Quality Program was called "PQRI"):
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Fig. 2 The "quality panel" of the Diabetes Dashboard

I call the little red, gray, and white circles "idiot lights". A more socially acceptable term is "traffic lights". They alert the physician to the actionable items for the task at hand: "Change the medications or diet to lower the blood sugar, order the cholesterol tests and annual urine micro-albumin test, and send the patient to the eye doctor."

Does this approach work?
Yes and no.

It is much easier to see what needs to be done. The effort to navigate around to find these 8 items used to take 60 clicks and about 6 minutes to find all 8 measures in our EHR. With the dashboard, it takes 6 clicks and a minute or two. That's a huge gain in efficiency and reduction in cognitive load. It's also safer and more accurate, because, frankly, most physicians would stop looking for that last item or two (the foot exam and eye exam are hardest to find) before wasting the the whole 6 minutes.

Do physicians improve their quality scores by making this more available?
Not necessarily. It's not a required view, and it's on page 2. If my nurse prints it out, circles the items needing attention, and thrusts it in my face (we are a finely-tuned team), then things happen. Otherwise, the 15 other details may get in the way. Information helps, but system processes need to change to get results.

Information Chaos

Researchers at the University of Wisconsin recently published a conceptual article on Information Chaos titled "Information Chaos in Primary Care: Implications for Physician Performance and Patient Safety" (J Am Board Fam Med, Nov-Dec 2011, 24:6, 745-751).

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Figure from the article at bit.ly/InfoChaos

I had never heard the concept of "Information Scatter" articulated before, but it resonated strongly with my experience as a family physician using a variety of EMRs over the past decade.

I recently did a post on using Information Dashboards. Think of a dashboard serving the same purpose as the dashboard in your car. It gives you the critical information you need for the task at hand.

  • When you start the car, you get the messages like "time to service your car" or "hey! check your engine".
  • When you are driving, you get speed, fuel status, turn signal indicators, bright light indicators, etc. 
    • You don't have to navigate somewhere else for additional information to do the task of driving.
    • You don't get unnecessary information that is not actionable during the act of driving.

Dashboards are well suited to reducing information scatter, and they help manage information overload when skillfully designed. A key feature that is often overlooked is to pare away all unnecessary data elements (removing words that don't add value).  For example, "lisinopril 10 mg daily", and not "lisinopril 10 mg 1 tablet oral daily".

Why dashboards?

Dashboard views should be the rule rather than the exception in EHR design
Physicians and nurses have to deal with complex data involving a number of realms, making quick judgments based on the overview of the patient's story.



Dashboards beat nested navigation in several ways:
  1. They minimize navigation.
  2. They reduce cognitive load by presenting the needed information in a single view. 
    1. Users don't have to think "What next? Where next? 
    2. Users don't have to use visual memory to recall the last page view: "What was that potassium value I saw seconds ago? Was that drug dose once a day or twice day?"
    3. Users can "scan the scene" to quickly see if there are any abnormals. If the view is "clean", then we can move on.
  3. They accommodate a variety of workflow styles. Methodical  or meandering paths work equally well when only the eye (and not the finger) does the walking. ABCDE sequence is as easy as AEDCB.
  4. They can be customized or personalized to meet unique user needs.
There are some caveats.
  1. Provide only the information needed for the tasks at hand. No more, and no less. That may mean leaving out detail from the grand view, while making that detail available when drilling down.
  2. Use visual cues. They don't have to be words. They do need to be recognizable at a glance. Think icons and traffic lights. 
  3. Try the designs out on real world users.

EHR Usability: An Illustrated Guide

I did a brief presentation at NIST on July13, along with about 2 dozen other usability geeks like me. The government recognizes the importance of having usable software if physicians and hospitals are to be expected to adopt electronic medical records. The ARRA incentives alone won't be sufficient if the software usability is lacking, causing physicians and other healthcare workers to lose productivity. They might break even, but many physicians worry that they won't, even with the financial incentives. Here are the pictures. You have to imagine my voice.

View more presentations from Jeff Belden MD.

NIST will be posting the slides and audio later. You might try here.

Dashboards from Sparklines: All Systems Go!

Dashboards will have several uses in the EMR environment.

  • ICUs for displaying those 3-page wide flowsheets of clinical data: intake, output, vital signs, lab, drips, PCA.
  • Chronic disease overviews: lab, home monitoring results, vital signs, prompts for next lab or immunization
  • Quality Improvement: compliance with standards, progress toward targets, peer comparisons
  • Pay for Performance: Budget, progress toward targets, return on investment
  • Management dashboards: trends, year-to-year comparisons, key performance indicators

Here are some nice examples

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Traffic light (colored dots of red) in the second column. Sparklines in the third column. Bullet graphs in the rightmost columns.

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Microbar graphs on the lowest row, with sparklines just above them.

After you sketch out a new dashboard with pencil and paper, you may want to dress it up to show off before you start spending engineer time on it.

Here is a nice PowerPoint template for making high-fidelity wireframe mock-ups.
Download Dashboard Template

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