Revised 14 Feb 2006 Prepared for: Indian Health Service Denise Grenier Prepared by:

1. 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

2. 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.

3. Templates list

4. 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)

5. 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.

6. 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

7. ‘Design your own’ – Positive yet Problematic

8. Additional issues: Default window for editing template

9. 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…)

10. Other issues: Poor use of real estate Template opens to essentially blank screen

11. Other issues: Absence of organizational categories

12. Other Issues: Layout Use of check boxes causes visual complexity and confusion

13. Other issues: Poor Alignment creates undo complexity

14. Alternative method of presentation Note: we have been informed that tables are not possible in the present implementation

15. Other Issues: Use of Radio Buttons – potentially problematic If provider changes mind cannot ‘unclick’ radio button Solution: use a 3rd radio button (N/A)

16. Other Issues: Visual complexity of screens What’s the difference between each of these? Note the complexity of reading and comprehending See Next slide

17. Alternative Method of Presentation Factor out common terms to decrease reading and complexity Participate regularly in heavy physical exercise, such as running, jogging, swimming, cycling, tennis, basketball or handball – 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

18. 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.

19. 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

20. 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