1. Redesign of the Columbia University Infobutton Manager James J. Cimino, Beth E. Friedmann, Kevin M. Jackson, Jianhua Li, Jenia Pevzner, Jesse Wrenn Department of Biomedical Informatics Columbia University College of Physicians and Surgeons

2. Infobutton Manager Redesign What is an infobutton manager? Why does it need redesign (metrics)? What methods were used? What happened?

3. Overview Infobuttons – context specific links from one system (clinical) to another (resource)

7. Overview Infobutton Manager (IM) – provides a set of context-specific links Infobuttons – context-specific links from one system (clinical) to another (resource)

10. Overview Utilization statistics from log files –Usage – how often is it used –“Selection rate” – when used, how often is topic selected –“Perusal time” – how long does it take to select a topic Gold standard: Health Resources (HR) page Infobuttons – context-specific links from one system (clinical) to another (resource) Infobutton Manager (IM) – provides a set of context-specific links

12. Overview Utilization statistics from log files –Usage – how often is it used –“Selection rate” – when used, how often is topic selected –“Perusal time” – how long does it take to select a topic Gold standard: Health Resources (HR) page Infobuttons – context-specific links from one system (clinical) to another (resource) Infobutton Manager (IM) – provides a set of context-specific links

13. Usage through October 2006

14. Selection Rate through October 2006

15. Perusal Time through October 2006

16. Methods Navigation study of IM version 1 Redesign of IM architecture Redesign of user interface Navigation study of IM version 2 Log file analysis of actual use

17. Navigation Study of IM Version 1 Seven typical clinical questions from NLM –One diagnosis query –Two lab queries –Three in-patient medication queries –Three out-patient medication queries –“Does cranberry juice alter the action of warfarin?” Subjects shown sample clinical system Evoke IM version 1 Attempt to answer the questions Usability analysis software to record sessions (Morae)

18. Redesign of IM Architecture Version 1: CGI returned set of links (HTML) Version 2: –Decouple user interface design from back end –Support platform-specific user interfaces

19. Redesign of User Interface Workflow (clicks): HR=many, IM=2 Aesthetics: similar font, color, graphics, layout Efficiency: –Scanability –Concise language –Keyword menus and buttons –Design consistency –Memorability (easy of reestablishing mastery) IM version 1: –Many concepts –Questions vary with concept and context –Questions are lengthy –Scrolling often required

20. Navigation Study of IM Version 2 Repeated method used to study Version 1

21. Log File Analysis of Actual Use Logfile provides record of clicks on: –HR page –Links in HR page –Infobutton icons –Links in IM Also provides immediate prior action Time stamp, user, IP address

22. Results Navigation study of IM version 1 –Convenience sample of six clinicians –Long persual times –Review of sessions confirmed wordiness and layout inconsistency were factors Redesign of IM Architecture: AJAX Redesign of User Interface

25. Results Navigation study of IM version 1 –Convenience sample of six clinicians –Long persual times –Review of sessions confirmed wordiness and layout inconsistency were factors Redesign of IM Architecture: AJAX Redesign of User Interface Redesign of User Interface: scanability, conciseness, keywords, consistency Navigation study of IM version 2

26. Perusal Times in Navigation Studies

27. Results Navigation study of IM version 1 –Convenience sample of six clinicians –Long persual times –Review of sessions confirmed wordiness and layout inconsistency were factors Redesign of IM Architecture: AJAX Redesign of User Interface: scanability, conciseness, keywords, consistency Navigation study of IM version 2 Log file analysis of actual use

28. Usage through October 2006

29. Usage through October 2007

30. Selection Rate through October 2006

31. Selection Rate through October 2007

32. Perusal Time through October 2006

33. Perusal Time through October 2007

34. Average IM and HR Monthly Statistics

35. Usage in Lab Contexts

36. Usage in Out-Patient Drug Contexts

37. Usage in In-Patient Drug Contexts

38. Usage in Diagnosis Context

39. Usage in Lab Order Entry Context

40. Usage in InPat Drug Order Entry

41. Selection Rate for OutPat Drug Context

42. Selection Rate for InPat Drug Contexts

43. Perusal Time for InPat Drug Contexts

44. What Happened? IM version 1 had a lower success rate and higher perusal time than the HR page This was confirmed in the laboratory Inspection of the user interface showed several possible problems IM version 2 appears, on inspection, to address the observed problems This was also confirmed in the laboratory The field experience did not confirm the laboratory experience

45. Why Did This Happen? Execution time adds a few seconds The HR page is static, while the IM is, by definition, dynamic IM uses a different paradigm (pull-push) Results varied by context, but not user type or level of experience Actual users are different, however

46. Users of HR vs. Users of IM HR  3: 1408 IM  3: 715 HR<3, IM<3 1160 248 Total Users 1/07-10/07: 2933

47. Now What? Educational e-mails New user interface may improve question- answering time Observational studies may be the only way to identify the rate-limiting step IM approach remains more efficient Users prefer IM over HR in some situations Version 3 (thanks, AJAX!)

50. Conclusions Good user interface design principles work Laboratory experience may not reflect reality Users do invest extra effort Selection rate and perusal time are not the only metrics of success

51. Acknowledgments This work was supported in part by National Library of Medicine Grant R01LM07593. The authors thank the test subjects for their time and effort. The authors also thank Dr. Rick Gallagher for providing the log files.