Table 6 Design Objectives for Development of Patient-Centered CDS

1 Ensure Patient Safety

1a Build algorithm content based on established clinical guidelines

Use of the NCCN guidelines for cancer pain management to guide algorithm content [63]

Based on published best practices, evidence-based content used for developing symptom management algorithms

Iterative review process of algorithm content and recommendations by multidisciplinary expert panel members

1b Identify at the beginning of a session potentially serious conditions for which continued use of algorithm could be harmful or life threatening

Additional characteristics of symptoms that suggest potentially dangerous or life threatening conditions identified. e.g., “in pain algorithm, besides enquiring about new or increased pain, adding a question that asksabout cramping or squeezing in chest or stomach”.

Questions added that identify severity and trigger “call now” advice.

CDS updated for immediate exit and to contact clinician if red flag was triggered

Distinguished nuances between pain symptoms, (e.g. new pain (e.g. fracture) and chronic pain)

Any time red flag is triggered, patient provided with specific suggestions on the screen.

Disclaimer needed to ensure safety (e.g. “In case of emergency, call your doctor or 911 immediately. Do not use this program for medical emergencies.”)

Warning placed on the welcome page of the program.

Bold font used as a way to capture patients’ attention.

There should be gradation of severity indicating what issues should the patient address first

Visual cues added to the report to help prioritize self-management strategies

Colors (red-orange-green) and fonts used to ensure patient reviewed specific aspect of the report. e.g. call clinician now

Report provided at the end can be viewed on the screen or as a printed report

1c Inquire about appropriateness of recommendations prior to offering advice

Provide guidance on why particular intervention should not be implemented (e.g. taking ibuprofen)

Content modified to provide reasons why a particular intervention would not be permissible (e.g. stomach ulcers)

Provide language to ensure any questions are directed to care team at all times

Report content updated to contact clinician if uncertainty about concerns on implementing recommendations

2 Communicate Clinical Concepts Effectively

2a Test word selection with intended end-users

Cognitive testing of terms and its interpretation

Modified wording utilized in assessment and recommendations to improve understanding of concepts

2b Develop explicit, detailed questions

Remove ambiguity of decision points

Added specificity of timeframes to questions to improve meaning (, e.g., “Did taking short acting pain medication give you relief from your pain within 30 min of taking it?”)

Reference specific medications and dosages as appropriate

Designed explicit decisions points to enable machine processing

2c Enhance communication with graphics, especially for clinical concepts

Improve system use by reducing content

Added “faces” and word anchors as part of the pain scale

Created content at a 5th grade reading level

Inserted images to re-enforce concepts (e.g., stop sign for emergency, picture to show acid reflux)

2d Provide lists to enable patient to identify specific items such as medications

Utilization of system could be improved by equipping patients with necessary information

Provided lists of most common medications in defined classes in a designated area of the screen for lookup as needed

Included generic and brand names of medications for ease of recognition

2e Provide educational information to promote understanding

Using CDS as a way to reinforce and provide education on why certain questions are being asked

Educational content added in final summary reports customized to their symptoms

Provided rationale of why certain questions were asked and promoted understanding

2f Enhance readability with font style, font size, content density, selective highlighting of words

Improve utility by improving layout of content

Used large and “heavier” font size to make text more visible

Reduced text density

Used a plain white background

Provided bolding to emphasize words

3 Promote Communication with Clinicians

3a Provide explicit instructions for patients regarding contacting clinicians about their concerns

Urgency of establishing clinical contact based on severity of the symptom needed(e.g. call right away vs. waiting 24 h)

Additional features added to generate report immediately on screen if patient triggered any of the emergency “red flag” questions and highlighted the importance of calling clinician NOW.

Post assessment report that provides guidance on what should be done and when.

Immediate instructions provided to the patient, on calling clinician, onscreen of the program and not just within the report.

Added explicit language on what patients should say when calling clinician.

Initial reports lost the message about the importance of communicating with the clinician

Report restructured to reinforce importance of contacting clinicians and keeping them informed of regimen changes. E.g. tell your doctor or nurse you are taking 200 mg of ibuprofen as needed.

Clearly communicate recommendations

Report modified into sections of: do now, do next and more suggestions, to help streamline and prioritize suggestions for what the patient can do and when

Lack of specification of which symptoms are available for assessment at beginning of the program

3 symptoms patients can choose in current system listed at the beginning of the program.

Patients advised to contact clinicians if experiencing symptoms not addressed by the system.

3b Encourage patients to notify their clinical care team about interventions that they have followed

Reinforce the importance of notifying clinicians about any interventions that have been initiated within the recommendations

Provided instructions about what patients should specifically tell their clinicians about interventions

4 Support Patient Activation

4a Determine what resources are available to the patient

Improve efficiency of the system and utilization by modifying question based on what patients have available to them

Added questions to determine what interventions had already been prescribed

Inquired if a prescription was already available for a recommended medication as a way to align with current therapy of the patient’s care team

4b Identify health beliefs that may impact interpretation of content and modify content accordingly

Modifying how content is framed

Content modified conveying meaning acceptable by patients. (e.g. pain medication vs. narcotics)

4c Determine what patients are willing to do prior to making recommendations

Improving look and feel of the system that quickly provides information and allows the patient to take an active role in their care

Provided explicit, detailed instructions that include dosage amounts, frequencies, medication list and lifestyle suggestions

Prioritized display in patient report to quickly and easily inform the patient on what they should do next

4d Provide explicit, detailed, actionable instructions to the extent possible

Inquired about what patients were willing to do prior to recommending an intervention, e.g., use of enemas for constipation

4e Personalize content, e.g., used possessive pronouns such as “my” or “your” where appropriate

Create an opportunity relate to the patient and provide self-management techniques

Changed the text to make it personable and user friendly, e.g., used possessive pronouns such as “my” or “your” where appropriate

5 Facilitate Navigation and Use

5a Designate consistent presentation areas on screen for repeated display of a specific type of information

Make it easy for patients to find information within the site

Posted medical terms with definitions in a specific area on the screen so end user can easily and quickly access information as needed

Avoided “pop-ups” because they felt to be interruptive and harder to navigate for a limited computer proficient user

5b Provide comprehensive set of selection options

Ensure all possible decision points are covered

Guidelines and best practices used for comprehensive coverage to ensure all possible selections covered for every decision node

5c Streamline data entry

Improve flow and provide feedback quickly

Introduced check boxes to cut down on number of questions required to determine what advice to provide and improved efficiency

5d Optimize workflow through questions

Inquiring about symptom characteristics at the beginning of the algorithm

Enabled selection of an item on a page to advance to the next page as appropriate

Directed patients to highly specific interventions

5e Optimize workflow through questions

Inquiring about symptom characteristics at the beginning of the algorithm

Facilitated patients starting at the appropriate place in the algorithm by inquiring what interventions have already been attempted

Introduced check boxes to reduce number of question and reduce redundancy

5f Track progress for patient

Promote efficient workflow

Added progress bar showing numeric value, not just graphic representing progress

Included “Go Back” function to allow patient to modify earlier responses

5g Accommodate patient changes and pauses

Offered multiple ways to start over such as: “Back to Start button” as well as tabs with symptom names

Included “Take a Break” button to allow patient to pause the program and come back to it again

5h Provide context for all interactions so that patient recognizes where he/she is within an algorithm

Added tabs as a way to indicate to the patient which algorithm they were in

Provided headers to supply context for each page anchoring the patient on where they are in a given algorithm

5i Ensure completeness and uniqueness of pathways through algorithm

Provided brief overview of different topics that were covered to orient patients at the beginning of a session

Re-enforced context and inter-relatedness of questions by showing question and answer from the previous page

Ensured that questions allow for a single non-redundant, unique pathway for all possible scenarios

Ensured that every pathway led to advice

5j Create tools that will function across multiple platforms

Assessed target patient population to determine that 85% of patients had access or knew how to obtain access to computers or smart phones

Created CDS tool design to function on Web, smart phone, or iPad