An accurate problem list is essential to providing better individual patient care across multiple care sites, and serves as a foundation for population management.
The Problem
For years, physicians have asked to improve the patient problem list feature in their provider documentation tool. Too much time of the physicians time is wasted managing the problem list, thus reducing their face to face time with their patients.
Where We Started
We reached out to 5 different client sites. At first, we conducted individual interviews with physicians. They explained their workflow and we observed how they went about documenting patient problems. This really helped us understand our physicians true needs.
Pain Points Discovered
Reranking a Problem List
We learned that physicians couldn’t reorder their patients problems without deleting and rewriting them (e.g. the physician wants to rank “diverticulitis” as the #1 problem, but in order to do this they must overwrite the fields in problem 1 and then do so for any other numbers that become out of sequence).
Providers had to copy and paste each problem (along with the details and plan) just to simply reorder the problems from the previous note
Status Management
Providers could search and add problems to the note, but had to manually select each individual problem to update the patient's problem list.
Providers had to navigate to the CDP to review or manage the patient's problems, and then return to their note to continue documenting.
Searching for a Diagnosis Code
Today, physician’s have trouble entering or finding the correct Diagnosis Code because they aren’t up to date.
Too much set-up and maintenance
Carrying Forward an Existing Problem to Another Note
Carry Forward of the problems and data from the previous document meant that the entire section was pre-populated with all prior problems, even though the previous may have had only a few of the problems.
Selecting Carry Forward problems, such as 1, 2, and 5, resulted in gaps in the numbering of the problems in the narrative.
Goals
After hearing all of the painpoints, we came out with some clear cut goals to accomplish:
• Allow physicians to manage the patient’s problem list from within a document
• Allow physicians to reprioritize/reorganize the problem list on the fly for the current note
• Allow physicians to easily update a problem’s status
Personas
Our primary users for this project were Physicians and our secondary users were Nurse Practitioners. We wanted to tailor this UI as much as possible to our physicians, while keeping in mind that Nurse Practitioners could also be chartering in the document.
Storyboarding and AB Testing
We began by storyboarding two different workflows that had potential of achieving the physicians goal of filling out their patients problems. Option A integrated the details and plan inside of the Problem List Management Tool. Option B kept the detail and plan section within the document, so after the physician added/managed problems and closed the dialog, physicians would have to then fill out the detail and plan section for each problem.
We A/B tested both workflows with physicians and Option B was the more efficient way of documenting problems. One of the reasons it was more efficient than option A was because as the physician carried over their patients note, they most likely would just edit the details and plan with any new symptoms. So by going with option B, we saved our physicians from extra steps and clicks. Physicians stressed the importance of data overload, notification fatigue and extra clicks, so we tried to improve upon those areas as much as possible.
Story Mapping
After storyboarding and gathering feedback from users, we started story mapping the whole project. The story map session was important for everyone on the team (Strategists, software analysts, UX, testers, developers and architects) to understand who we were designing for, what workflows were being improved upon, and how much of an effort this would take. Going through this session really helped the team to keep the user in mind first.
Low Fidelity Wireframes
With our team having access to the 5 client sites (over 20 physicians), I would have a new iteration to show physicians every week. This allowed us to move quickly and test workflows that we had reservations about.
Formative Usability Test
We tested key interactions like adding, ranking, filters, carry-forward and reprioritizing. We received a lot of valuable insight during our tests. One example of that occurred in the add and rank test, we realized when adding a problem, the physician wanted it added and ranked as #1 on the list. Most times when physicians are adding a new symptom it is something that they need to monitor like a hawk. We iterated on this design and tested again with physicians. This time physicians were pleased with the add/rank interaction and were more efficient the second time around.
Below are some of the tasks that we planned and used within our formative usability test.
Task 1: Adding and Ranking Problems
You are writing the Cardiology H&P (Admission History & Physical) for your new patient (I will give you the name). His current complaint is Chest pain and you suspect that it's Myocardial Infarction. During your examination he told you that his past medical history includes Coronary Arteriosclerosis, Hypertension, Diabetes Mellites
II, Hyperlipidemia, Anemia.
In the Problem Management tool, add the patient's current and past problems and rank at least 3 problems you will be treating during this visit.
Task 2: Change Filter to "All Status" -- check history
You're writing a H&P Note for your new patient (I will give you the name.) His current complaint is ankle swelling accompanied by unexplained shortness of breath, excessive drowsiness or fatigue, persistent nausea and high blood pressure. You decide to treat him for Renal Artery Disease.
In the Problems Management tool, add the new problem and rank at least 4 that you expect to treat during his stay.
Task 3: Carry-forward & Reprioritize problems. User will move Diverticulitis to be the #1 problem*
Your next patient was treated by a different Hospitalist from yesterdays shift. You examine the patient today and decide that the problems need to be re-prioritized in your note.
In your progress note, re-prioritize problem Diverticulitis so that it is ranked as #1.
High Fidelity Wireframes
After confirming the workflow with physicians, I began designing the high-fidelity screens for my developers. I used Sketch to design the screens and Invision to prototype the workflows and interactions.
Takeaways
Without User Centered Design, we would not have been able to successfully design a product that paralleled with our physicians process. Client sites have begun upgrading to the new Problem List Management Tool in their Provider Documentation Application and it already has reduced unnecessary documentation time. Physicians now have more time to focus on their patients and not on a screen.