SMART MEDICAL SOFTWARE SYSTEMS FOR DUMMIES?

The Case for a User-centered Systems Design

Detlef Zuehlke, Gerrit Meixner

German Research Center for Artificial Intelligence (DFKI), Trippstadter Strasse 112, Kaiserslautern, Germany

Ulrike Klein

University of Heidelberg, Department of Internal Medicine, Hematology/Oncology

Im Neuenheimer Feld 410, Heidelberg, Germany

Keywords: Human-Computer Interaction in Health Care, User-centered Development, Usability of Medical

Information Systems.

Abstract: In this position paper we ask the question of whether current medical software systems adequately support

the “dumb users” in their routine work, or whether the software systems are rather function-oriented and

their development far removed from reality. In a multi-year study, the medical faculty of the University of

Heidelberg and the German Research Center for Artificial Intelligence (DFKI) cooperated on a review of

the current situation in medical software systems. The first project involved the joint development of a

prototype of a user-centered software system for the allogeneic stem cell transplantation procedure.

Additionally, a comprehensive survey was conducted among the medical staff of the Hematology and

Oncology Department at the Heidelberg University Clinic. The results of both the project and the survey are

presented here.

1 INTRODUCTION

When we look at the situation today in the area of

clinical IT systems, we can find major advances in

the performance capacities of modern software

systems, but must also note their rapid penetration

into almost every facet of the daily clinical routine.

A myriad of very good software products now exists

for patient administration, resource management,

personal data administration, drug prescriptions, and

many other activities, all of which have proven their

worth in numerous clinics.

Surveys among clinical staffs have shown,

however, that the operation of the software systems

has very little to do with the actual tasks performed

by the operator. Developers have a different way of

looking at the systems than do the future users who,

in their work, must frequently use several different

systems, each supplied by a different manufacturer,

in parallel in order to complete their tasks (cf.

Nielsen, 2005). In the event of a problem or when

the user rejects the software support system, it is

often all too easy to put the blame on the “dumb”

user. The situation is briefly introduced in the

following example.

2 SMART TRANSPLANTATION

The aim of the Smart Transplantation Project was to

determine how software systems could provide more

efficient support to medical personnel (physicians,

caregivers, transplant-coordinators) during complex

medical procedures (Meixner, Thiels and Klein,

2007). To this end, in 2007 the authors conducted a

situational analysis into the subject of software

support for allogeneic stem cell transplantation (one

of the most complex medical procedures) at the

Heidelberg University Clinic. In a comprehensive

study, user requirements, relevant data requirements,

work processes, etc. were examined by means of

observation and expert interviews. In the process, a

series of significant findings were observed.

Notably, we found that members of the medical

staff must make safe and proper decisions,

effectively and efficiently even when

350

Zuehlke D., Meixner G. and Klein U. (2010).

SMART MEDICAL SOFTWARE SYSTEMS FOR DUMMIES? - The Case for a User-centered Systems Design.

In Proceedings of the Third International Conference on Health Informatics, pages 350-354

DOI: 10.5220/0002756303500354

 SciTePress

existinginformationsources

(ISH,AiD,paperetc .)

Allogeneictool

Figure 1: Integration of various information sources into the task-centered allogeneic tool.

performing under time pressure (stress). Other

aspects like the simple and intuitive use of the

operational interface (usability) or joy-of-use

(hedonics) are of equal importance.

An initial prototype was then developed with the

aims of providing optimal support to the medical

staff throughout the complete workflow of

allogeneic stem cell transplantation and integrating

the various existing IT-systems, for example, paper

based files, hospital and drug information systems

into one application (see figure 1). A previous

analysis of tasks revealed a software system that

included the following functionalities: extraction of

medical data from several different sources,

structured presentation of processed information,

and automated generation of medical documents

such as physician’s letters or pharmaceutical plans.

Furthermore, the procedure for allogeneic stem

cell transplantation was broken down into a 5-

phased treatment plan and placed onto a timeline.

The different information needs in each of the

individual phases (patient history, donator search,

preliminary examination, inpatient stay and follow-

up treatment), had to be presented according to the

respective needs of the various users. This task-

centered approach resulted in efficient search and

documentation of information and, in this way,

provided some relief to the medical staff. In

addition, the operational interface was adapted to the

needs of the respective users with various screens

developed on the basis of user groups.

Prototypes designed on the basis of the findings

in the Smart Transplantation project revealed

problems, for example, the time consuming

searches, the redundant data entries, or the use of

different software to perform the various tasks,

which could be significantly reduced by the

introduction of an integrated software system.

This project was limited in scope to one complex

medical procedure. The overall situation pertinent to

software support of medical professionals within one

department of a major healthcare clinic was

investigated by the follow-on survey.

SMART MEDICAL SOFTWARE SYSTEMS FOR DUMMIES? - The Case for a User-centered Systems Design

351

3 CLINICAL SURVEY

More than 30 staff members of the Department of

Hematology and Oncology at the Heidelberg

University Clinic participated in an online survey

which asked about various areas of application of

Information and Communications technologies

(ICT) within the hospital. 94% of those asked

responded that IT applications are critical to the

daily routine at the clinic and 90% said more than

50% of their work involves the use of computers;

58% even reported more than 75%. Important

criteria for the respondents was not only a timely

system response but also that the system be efficient

and user friendly. The responses were ambivalent

concerning the current state of integration of the IT

applications in the daily work routines. No clear

conclusions can be drawn - positive or negative –

from these answers. However, when we evaluate the

responses in terms of the question about IT systems

optimization, the dominant answers mention, besides

the timeliness, the integration of the different

individual applications into one system and the

elimination of redundant data entries. The analysis

of the individual systems used in this job area

showed major deficits in usability and effectiveness,

especially in the accounting and technically oriented

administrative applications. The assignment of

responsibility for specific functions was analyzed in

terms of the professional medical staff and the IT

applications. The functions assigned to the computer

systems were: the logistics, the processing of

previously selected data as well as the

recommendation of appropriate diagnosis and

therapy. The actual selection of patient data and the

decision making for diagnosis and therapy were

assigned without exception within the sphere of

responsibility of medical professionals. Another

subject area in the survey solicited attitudes about

decision support systems. 82% of those asked

reported no knowledge or, only a vague idea of what

the term means. After a brief clarification,

respondents were asked to comment about the uses

and benefits, the reliability, the prospect of success,

and the acceptance of decision support systems.

While the benefits were generally given a high

rating, the reliability and acceptance were rated

rather low. Nevertheless, 60% said they would

follow the recommendations of the decision support

system.

Overall, the findings of the survey show IT

technology in hospitals has attained an important

status and with the optimization of the software

structures, tasks and processes can become more

efficient, quality can be improved, and performance

stress can be reduced (time pressures). The concern

that computers will replace the professional staff

seems to have retreated in the face of the view that

IT solutions can effectively support and simplify

their work.

4 CONCLUSIONS

The contemporary leading IT applications for

hospital information services and, by extension, the

major patient data administration applications are,

with some exceptions, oriented for historical reasons

on business and accounting theory. This not only

makes them quite user-unfriendly, fairly inefficient

for a clinical environment, but also dangerous

(Nielsen, 2005; Koppel et al., 2005). At the same

time, the users recognize their dependence on

computer systems in their daily clinical routines and

criticize the inadequate level of integration among

the individual systems and the resulting need for

redundancy, poor functionality, and deficits in data

presentation. These smart systems may be brilliantly

programmed, but they go right around the actual

requirements of the various user groups found in

hospital operations. For example, some feature that a

business accountant appreciates may be totally

useless for the doctor. The issue is not the ignorance

of the user but rather, the historical development of

hospital software and the apparent lack of interest in

developing software that would satisfy the everyday

job needs of a nurse or an internist. Among this

group, the longstanding opinion that computers

would disrupt the clinical activities has been

replaced by the desire for IT systems that support

their work through integration, efficiency, and

appealing presentation of important data. The user

community today brings a readiness to use the wide

range of opportunities made possible by computers.

They are by no means dumb or unwilling, but they

simply must rely on IT concepts that, to be of any

use in practice, must be tailored to their needs. We

saw this, for example, in the willingness to use

decision support systems and not categorically reject

them; and, again in the re-assignment of some

responsibilities from the medical staff to the

intelligent software solutions. The potential is great

in daily healthcare routines for IT solutions that

isolated applications will never be able to satisfy.

Much more, it will require integrative,

comprehensive, and user friendly software products.

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Figure 2: The interdependence of human-centered design activities (ISO, 2009).

One possible solution lies in user-centered

interface design which has long been a decisive

factor in the acceptance of new software. However,

in the fields of healthcare and medicine this

development still presents an enormous challenge.

Truly user friendly operational interface designs can

only be assured under a systematic development

process (Zuehlke and Thiels, 2008).

A user-centered development process is broken

down into several iterative phases (see figure 2).

Beginning with the user and context analyses,

requirements are defined for the operational

interface, implemented in (visual) prototypes, and

then tested and evaluated by current and future users

(ISO, 2009). Especially the evaluation of visual

prototypes is important, because prototyping and

testing can focus on specific improvements in

metaphors, mental models, navigation, interaction,

and appearance (Marcus et al., 2000).

None of these phases may be pursued in

isolation, but rather, they should be seen as

overlapping. The focus during the analysis phase is

on the users (e.g., doctors and caregivers), their

tasks, and their work environment. Several different

methods such as surveys, observations, or

questionnaires are used to identify and develop a

comprehensive list of requirements (cf. (Holzinger,

2005)). A parallel evaluation, for example,

employing structural, paper, or functional

prototypes, allows users to be integrated directly into

the test and evaluation process of the development

concept.

It is especially important to convince

manufacturers, developers, and buyers of the user-

centered development approach. The benefits are

already clear and include time and cost savings,

improved software quality and greater user

satisfaction. The successful application of user-

centered development processes for operational

interfaces in medical field has already been

demonstrated, for example, in (Meixner et al., 2008).

A key problem is still whether the users of

medical software systems are simply not smart

enough (PEBKAC: Problem Exists Between

Keyboard and Chair) to operate the systems

correctly and efficiently or, perhaps, whether the

software systems are simply inadequate, not user-

centered and, to this extent, the product of intelligent

development. In the future, the development of

medical software systems will no longer be oriented

on technology and business accounting, but will

focus more on the actual users and user support in

the daily clinical routines.

In this respect, there must also be a serious

review of the myriad of different isolated

applications and special system solutions in the

medical field. An appropriate standard for the

development of graphic displays based on a generic

SMART MEDICAL SOFTWARE SYSTEMS FOR DUMMIES? - The Case for a User-centered Systems Design

353

operational interface would be a major step towards

a standard solution. This would facilitate integration

of existing expert systems under a common

operational interface. The main benefit of such a

(platform independent) standard user interface

description language for medical software systems

(e.g. developed as a XML-language) would be the

easy adaption to specific constraints and conditions.

There would be no need for using different graphical

widget libraries – just one standard which could also

be automatically transformed into specific final user

interfaces (e.g. source code). Successful Examples

of such languages in computer science are the User

Interface Markup Language (UIML) (Ali, Pérez-

Quiñones and Abrams 2004) and the eXtensible

Interface Markup Language (XIML) (Puerta and

Eisenstein 2002).

ACKNOWLEDGEMENTS

This work was funded (in part) by the German

Federal Ministry of Education and Research under

grant number 01 IS 09027 C. The responsibility for

the content of this publication lies with the authors.

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