# Presentation: 484585

## Text Integration Utility – Preliminary Examination of Behavioral Health Templates Implementation within EHR

- Revised 14 Feb 2006
- Prepared for:
- Indian Health Service
- 	Denise Grenier
- Prepared by:
- Hal Miller-Jacobs

## Text Integration Utility

**Introduction**
**A review of the Text Integration Utility Templates for Behavioral Health providers was conducted.  These Templates are provided on the ‘Notes’ tab within EHR (Electronic Health Records)  **
**A subsequent teleconference pointed out the limitations of the tool (e.g., tables are not possible)**
**This brief report summarizes the major points mentioned and provides several recommendations that can improve the usability of the Templates, short of a major redesign effort for how templates are generated.**

**Notes:**
IHS requested that Human Factors International review the Text Integration Utility Templates and provide comments on the usability of the templates using our expertise in user interface design.  These templates will be used by behavioral health providers in documenting the encounters with clients. No actual data collection was requested nor obtained from users.
A subsequent teleconference identified the limitation of the development tool which severely limited the possibilities for enhancing the interface. For example, the tool does not provide the capability for using tables that would enhance the alignment and clarity of many of the templates.
Recognizing that a major redesign effort is not possible, this brief report identifies the major issues and recommends fixes within the capabilities of the tool. 

## Templates list

**Templates list**

**Notes:**
This is a listing of the nine basic Behavioral Health templates (listed under Behavioral Health).  

## Positives of the current approach

**Detailed coverage of every possible situation plus space for comments **
**Can be customized for a particular population or location**
**Covers wellness, traditional, and western perspectives**
**Adult & Child/Adolescent – specific **
**Use of progressive disclosure (i.e., presenting alternatives when appropriate)**

**Notes:**
There are many positive features of the current TIU (Text Integration utility)., including:
Every possible situation in behavioral health is covered with space for additional comments
The templates can be customized to a particular population or location using the ‘Design your own’ feature
All perspectives of behavioral health are covered including Medicine-Wheel approaches
Templates are specific to adults or children reflecting the different conditions/needs
Not all information is presented at once; if a specific item/issue is relevant, the choices associated with that item/issue appear (progressive disclosing the relevant items)

## Basic Question & Response

**Are providers of Behavioral Health familiar with:**
- EHR?
- Notes tab?
- Implementation of Templates?
**Response:**
- Varies widely across provider population
**Therefore:**
- Implementation must consider providers at the low end of knowledge without sacrificing the capabilities required of those at the higher end.
**	**

**Notes:**
While the TIU is very robust, it is directed at the sophisticated user.
We had questions as to the familiarity of Behavioral Health personnel with EHR itself, the Notes tab (where TIU is located), and the methods in which the templates are implemented.
The response was that there is a wide variety of knowledge across the provider population; some are quite adept while others are unfamiliar with even EHR.
To be effective and serve the needs of all providers, the implementation must consider providers at the lower end of the knowledge continuum with out sacrificing the robustness of the implementation for the providers at the high end.  The current implementation does not appear to consider those at the lower end, calling into question its practical usability!

## Some of the Issues

**Number of Templates (9 basic; over 40 when Designing Your Own)**
- Requirement to select a template a priori
- System knows if patient is adult or child/adolescent – why not only present appropriate templates?
**Terminology – is it clear to all providers?**
- Standard, Wellness, Traditional
- Five are all ‘Biopsychosocial Assessment’
- JCAHO PE.1.8
**No overview of what is ahead (some templates are single screen others many multiple screens)**
**Tree structure & icons may not be understood**

**Notes:**
Some of the issues that have been identified include:
Close to 50 different templates that the user has to select a priori.  This selection could be simplified. For example, the system knows if a child or an adult is the client.  Why not present only the appropriate templates, reducing the number?
Terminology may not be familiar to all providers, e.g., Standard, Wellness, and Traditional.  Note the similarity of terminology in many of the templates, e.g., Biopsychosocial Assessment in used in 5 of the templates and is also listed in another template further down the listing.  Use of non-distinctive terminology can cause errors in selecting the wrong template.   How many providers will be familiar with the term JCAHO PE.1.8?

## ‘Design your own’ – Positive yet Problematic

**‘****Design your own’ – Positive yet Problematic**

**Notes:**
In addition to the 9 basic templates, there are over 40 templates for Designing Your Own! (the view above is partial and shows only what could be shown in a single screen). While this listing provides a complete capability for customizing any template, the shear number of possibilities can be daunting!  
There should be a better method for capturing the data rather than 50 individual templates!

## Additional issues: Default window for editing template

**Additional issues: Default window for editing template**

**Notes:**
This is what a template looks like when selected in the default mode. Note that it only covers a small amount of screen real estate requiring a lot of scrolling.  Would be better to default to use more screen real estate.

## Other Issues: Inconsistency of Implementation

- Sometimes only titles are listed (Childhood Health) and expanded when check marked.
- Sometimes all sub areas are listed immediately (emotional/behavioral...)

**Other Issues: Inconsistency of Implementation**

**Notes:**
Because of the inconsistency, the user cannot develop a universal mental model of what happens when a template is selected.

## Other issues: Poor use of real estate

- Template opens to essentially blank screen

**Other issues: Poor use of real estate**

**Notes:**
If the template is selected, why require the user to select the check box to populate the screen?

## Other issues: Absence of organizational categories

**Other issues: Absence of organizational categories**

**Notes:**
Could this listing be organized into meaningful categories?

## Other Issues: Layout

- Use  of check boxes causes visual complexity and confusion

**Other Issues: Layout**

**Notes:**
A chart would be more readable.

## Other issues: Poor Alignment creates undo complexity

**Other issues: Poor Alignment creates undo complexity**

**Notes:**
Alignment would make this screen far more readable and “scanable”.

## Alternative method of presentation

|  | Mother | Father | Sibling | Aunt | Uncle | Grandparent | N/A |
| --- | --- | --- | --- | --- | --- | --- | --- |
| Alcohol/Substance abuse |  |  |  |  |  |  |  |
| History of completed suicide |  |  |  |  |  |  |  |
| Depression |  |  |  |  |  |  |  |
| Schizophrenia |  |  |  |  |  |  |  |
| Bipolar Disorder |  |  |  |  |  |  |  |
| ........ |  |  |  |  |  |  |  |
| ....... |  |  |  |  |  |  |  |

**Alternative method of presentation**

- Note: we have been informed that tables are not possible in the present implementation

**Notes:**
While tables are not possible with the tool, are there no methods improving the alignment?

## Other Issues: Use of Radio Buttons – potentially problematic

- If provider changes mind cannot ‘unclick’ radio button
-   Solution: use a 3rd radio button (N/A)

**Other Issues: Use of Radio Buttons – potentially problematic**

**Notes:**
Once a radio button is selected it cannot be unselected, only changed to the other value, (as opposed to a check box that can be unselected). Use of a third radio button with an N/A label can solve this problem.

## Other Issues: Visual complexity of screens

- What’s the difference between each of these?

**Other Issues: Visual complexity of screens**

- Note the complexity of reading and comprehending
- 					See Next slide

**Notes:**
Only a few words distinguish between these choices  - see next slide for recommendation.

## Alternative Method of Presentation

- 	Run less than mile or less than 30 minutes per week
- 	Run 1-5 miles or 30-60 minutes per week
- 	Run 5-10 miles or 1-3 hours per week
- 	Run more than 10 miles or more than 3 hours per week

**O**

**O**

**O**

**O**

**O**

**Alternative Method of Presentation**

- Factor out common terms to decrease reading and complexity

**Notes:**
 Factoring out the common terms makes the information far more readable and “scanable”.

## Other issues: Distinguishing between Label & Content

**Other issues: Distinguishing between Label & Content**

- Assuming that it was not possible to only show the problems with content, spacing and/or alignment of labels and content would make it more readable.

**Notes:**
After selection of the appropriate template choices, the results would appear as on the right. Note that it is not easy to quickly scan the relevant problem areas.  In the absence of tables, some type of separation and alignment would definitely help.

## Alternate Approach – Flow Chart

**Rather than the Template approach, consideration should be given to a flow-chart approach for providing the capability of text integration.**
**Rationale -**
**There is a finite set of  specific categories that are required by the Joint Commission of Accredited Healthcare Organizations (JCAHO); these consist of addressing the:**
**Physical**
**Nutritional**
**Social**
**Emotional**
**Psychological**
**......**

**Variations on the original flow charts could be presented that would provide the appropriate categories in each of the above areas for Wellness, Medicine Wheel and Standard versions**
**This would ensure that all areas are covered without having to a priori select a template that matches the criteria**

**Notes:**
This approach will require further elaboration and investigation.
It may however simplify the process and ensure compliance with the JCAHO requirements.

## In summary

**Templates may be complete – but implementation is not ‘Provider friendly’. An alternate approach (Task Flow) should be investigated**
**Recognizing that there are limitations as to what can be accomplished in the present implementation, consider:**
- Defaults wherever possible (e.g., Adult or Child/Adolescent)
- Overview of items within template
- Clarification of terminology which may not be universal
- Improved organization of categories
- Spacing of items to simulate alignment and tables where possible
- Factoring out common terms
- Using screen real estate more efficiently (e.g., larger default window)
- Third choice for radio buttons

**Notes:**
Further investigation of the usability of TIU is recommended.