Collaborative goal setting has been shown the potential to build a trusting relationship between clinicians and patients as well as improve the competence of patients in making behavior change. Obesogenic diet is a major driver of type 2 diabetes, cardiovascular disease, and cancer, which disproportionately affect low income, racial/ethnic minority patients via disparities in chronic disease incidence, treatment, and prognosis. Given these links, it is imperative the healthcare system make diet a standard component of chronic disease prevention and management; yet, diet is addressed inconsistently and ineffectively in primary care, the setting in which most patients’ chronic disease risk is addressed. PCPs are uniquely positioned to promote dietary behavior change through high impact collaborative goal-setting, which has been linked to patient self-efficacy and behavior change and is a key element self-management education guidelines. This is especially important for patients from low income and racial/ethnic minority communities who are less likely to have time and resources to seek out specialist care.
Oct 2019 - May 2020
Market Research, Comparative Analysis, Heuristic Evaluation, Literature Review, Affinity Diagram, User Interviews, Journey Mapping, Wireframe, Prototype, Usability Testing, Report & Documentation
This project focused on redesigning CDS 1.0 to assist physicians with visibility to patient diet and lifestyle and help facilitate the analysis of that data so that effective prioritization can take place during the primary care visit.
CDS 2.0 is intended to provide my client with a user centered solutions that will assist physicians by leveraging health information technology to lead effective diet counseling in the primary care setting while leveraging opportunities to improve aspects of their current clinician workflows.
Primary Care Physicians
01 Market Research
To start with the research, we conducted the market research on 11 software and websites mostly indirect competitors to identify the key components of collaborative goal-setting in a general context, and to establish the relationships with their attributes for improving health outcomes in the primary care setting.
a. Collaborative goal-setting that facilitates behavior change is not well represented in the existing EHRs.
The existing EHRs lack systemic process for goal setting and action planning, which are essential to promote behavior change of patient with chronic diseases. Medical doctors still use "note" section or no formalized method to document the process.
b. SMART goal setting approach is effectively introduced in goal setting and goal management software.
SMART stands for specific, measurable, attainable, relevant, and time-based. These attributes contribute to successful goal setting that helps drives achievement in behavior change.
02 Comparative Analysis
We created substantial design clutters of color themes, design patterns, potential features, etc. as design materials and inspirations for the design phase.
a. Data visualization that facilitates diet assessment helps both patients and physicians to quickly identify areas need improvement
The software for private nutrition practices (NutriAdmin, Nutrium) provides a multitude of visuals for nutritional analysis that instantly helps identify nutrition consumption and deficiency.
b. Goals are tailored to individual's unique needs.
Personalized goal setting and action planning can be achieved by leveraging health information technology that collects patient's medical, physical, mental needs and values.
03 Heuristic Evaluation
We evaluated CDS 1.0 based on 10 usability heuristics for user interface design by Jakob Nielsen to identify potential usability issues and which would be used to inform the design decisions in CDS 2.0.
a. Aesthetic and minimalist design
The color codes for goals to indicate different levels of diet performance may cause readability issue because the background doesn't have enough contrast with the text.
b. Help and documentation
The patient may lack knowledge of food sources for specific food group. Easy assess to the food list can effectively reinforce the nutrition conversations between the patient and the physician.
04 Literature Reviews
To understand the current application of collaborative goal-setting in the clinical setting and the effectiveness of driving the success of the treatment plan.
a. Collaborative goal-setting drives patient's buy-in in their competence of completing a goal.
The patient's willingness to achieve a goal is just as important as the patient's competence to achieve it.
b. Patient-centered approach trumps disease-centered approach especially for the patient diagnosed with multiple chronic diseases or comorbidities.
Collaborative goal-setting helps drive a patient-centered approach where the patient's needs will be addressed based not just on medical diagnosis but on individual's unique and complicated reality.
Observations & Analysis
Subject Matter Experts Interviews
Two rounds of interviews were conducted. 7 medical doctors and 2 registered dietitians. The first round aims to establish an understanding of the dietary needs of patients and the physician workflow in a clinical setting. The second round focused on the requirements physicians had for software used within their flow as well as design implementations that would benefit patient outcomes.
PCPs and patients endorse the importance of addressing diet in primary care; however, doing so effectively is challenging because PCPs have limited training in nutrition. PCPs lack four key elements needed for effective diet counseling:
1) access to patients’ diet history data
2) expertise to systematically analyze diet data to identify and prioritize dietary problems
3) training in dietary behavior change goal-setting
4) enough time to spend with each patient
We collected all the observations from the interviews and grouped all similar themes together to find actionable insights.
The Physician-Patient Journey in the Primary Care
Then we mapped out the physician-patient journey to gain a holistic view of the current clinical workflow. This map helps us to quickly spot major pain points and opportunities for improvement. The experience of the primary care physician (PCP) in a standard appointment* represents a common set of tasks that every PCP must ensure is prepared, actioned, and recorded in a timely and compliant manner. This experience map doesn’t represent what a PCP experiences during every individual patient appointment however, it provides a high level overview of the process and identifies the areas where a clinical decision support tool may make the most impact.
How might we leverage the health information technology (HIT) to capture patient data and aid PCPs in adopting brief, data-driven, collaborative goal-setting to improve patients' diet?
Targeted patient groups
We decided to focus on the use case of patients diagnosed with prediabetes and diabetes because this is a major worldwide epidemic that more than 415 million individuals are suffering.
Dietary data collection
In the original proposal, CDS 1.0 is a REDCap-based concept that patients' diet and lifestyle data will be captured through NCI validated ASA24. However, the research findings showed that completing the diet recall is too time-consuming and physicians do not recommend ASA24 in the primary care setting if this is something that expects extra effort from the staff. CDS 2.0 will look for an alternative of data collection that is compatible with the REDCap as well as the current clinical workflow.
Our participants highlighted many areas of improvement for nutrition counseling within the physician workflow. We focused on six that we felt would best support the physician in conducting effective diet counseling.
Patients aren’t always very forthcoming about their diet…I have to make sure that they’re being honest. It’s establishing that trust.”
CDS 2.0 provides space for motivational interview techniques in the presentation and explanation of patient lifestyle and nutritional information.
A twenty-four hour recall is sometimes pretty challenging, not really reflective of what they’re doing.”
Flexible options for diet data collection
To promote quality data collection, add context, and save time the diet recall in CDS 2.0 is kept flexible and is completed on the patient’s time and at their pace.
People won’t remember what you told them.”
Identify potential improvement areas
Behavior change takes place across many stages and cannot be achieved in the exam room alone. CDS 2.0 recognizes the flexibility necessary to support the patient through all stages of behavior change.
Collaborative Goal Setting
I’ll focus on one to three specific goals for next time.”
CDS 2.0 recognizes that physicians approved of the preset goals in CDS 1.0 but showed interest in the creation of tailored goals that were specific to the patient.
Many people just don’t have a clue why the weigh what they weigh based on what they ate because their perception is that they’re not overeating.”
One-stop shop for educational materials
Efficient storage, delivery, and consumption of educational material in CDS 2.0 is designed to provide time savings for physicians and improve outcomes for patients.
…You only get twenty minutes per patient for everything, if I have people waiting…literally a couple minutes. Otherwise, I’ll just take more time.”
Integrated with current EHR
Physicians stated that any software must be interconnected with their EHR. CDS 2.0 will save time on data collection, record-keeping, and collaborative goal setting by allowing the physician to work more efficiently and without any disruption to their current flow.
Based on our findings and insights from the research, I sketched out multiple potential solutions that could address both patient and physician needs. Then we discussed and voted for the most feasible solution within the team.
We decided on a dashboard that enables the physician to monitor the performance of patients' labs, diet, lifestyle and goal progress, and to share the screen with the patient if necessary intended to optimize the patient-provider communication. This solution will also be addressing the poor-integrate to remove workflow obstacles and, at the same time, incorporated diet, which is an important social determinant of health into the primary care setting.
Due to the pandemic, recruiting participants and coordinating time with them became extremely challenging, especially when the participants were medical doctors. However, we were very lucky to be able to test out the first few versions of mockup and gained valuable feedback for iterations.
We made some changes to the content, features, design, and layout of the mockups after talking to the participants.
01 Replaced cardview with listview for better identification
Multiple columns of cards prevent physicians from quickly browse through the data, while the list view allows the physician to scan the data from top to bottom reducing the frequency of eyes averted to different directions and identify the abnormalities in the data promptly.
02 Manage the data more efficiently
Moreover, the list view allows the user to efficiently manage the data and see the changes right away when filtering and sorting applied. Without hiding the filtering and sorting options, the user would be more informed about what actions are available.
03 Tailored the nutrition data more aligned with physician's agenda
The original design provided too much information that cluttered the screen and that was unhelpful for clinical decision making. In the follow-up interview sessions, we specifically targeted to the content-wise questions to understand what agenda physicians have already been doing in primary care encounters. Then we came up with the dashboard customization function that allows the user to tailor the screen to their preference of nutrition-related data set.
04 Made every space on the goal-setting page count
After talking to more participants, we began to have more understanding of what data they would value on the dashboard, so we were able to identify and remove the redundancies in the design. Considering the scenario that the "previous goals" could play critical parts in positive affirmation based on the goal performance as well as in long term achievement, we relocated the "previous goal" to the left-hand side which facilitates more attention from physicians and patients during the conversation.
05 Removed the effort of input
Meanwhile, this modification left us more creative space to introduce the print list that will be attached to the right side of both the collaborative goal-setting section and the education section. To streamline the process of delivery, we take a relational approach to automate the process of adding relevant educational materials based on the selected goal(s) in the goal-setting section.
Patient Data Overview
CDS 2.0 starts with a summary of the current patient that outlines recent goals, medical history, and lifestyle highlights that can be used as the foundation for motivational interviewing employed during the appointment.
Flexible patient tracking opportunities have been built into CDS 2.0 to allow physicians to integrate contextual clues into patient profiles helping streamline patient-to-patient transitions.
Visualization of labs, diet, and lifestyle data
Presenting information is a way to increase the patients' sense of control and investment in addressing the concern at hand. We’ve leveraged visualization techniques that allow the physician to communicate complex concepts while reinforcing the effect that behavior change can have over time.
Advanced visualizations can be tailored to the patient and the conversation. With EHR data providing visibility to lab results and patient sourced data providing visibility to dietary and lifestyle changes, new themes can be identified and influence goal selection that can improve patient outcomes.
Data highlights for talk points
Behavior change begins with the conceptual understanding of the problem and continues with long-term visibility to how changes
affect patient health. CDS 2.0 provides simple but impactful visualizations that can connect to diet and lifestyle trends.
Many studies show that a majority of what is discussed in physician appointments is forgotten by patients shortly after leaving the physician’s office. CDS 2.0 provides simple graphics to assist with the explanation of complex concepts. Additionally, to reinforce patient education, much of this patient information is available on the CDS 2.0 paired mobile application that is used to capture the patient lifestyle and nutritional data.
Promptly identify dietary needs via color codes
CDS 1.0 goals have been integrated in to the nutrition dashboard highlighting areas where the patient shows the most opportunity for improvement. This allows the physician to limit immediate goals without limiting visibility to patient nutrition.
Diet recall is now completed with food entries. This style of recall can be completed at various levels. For the novice that chooses to spend less time “logging”, pictures can be utilized. Advanced users may track more specific measures of the food they consume such as calories, weight, etc.
Custom dashboard fitting various patients' needs
Lifestyle habits can be logged to better track out the patient’s social circumstances may affect future behavioral change allowing the physician to tailor guidance based on their specific situation.
Many of the features of CDS 2.0 are intended to allow the physician to adopt technology that fits their workflow. The nutrition screen can be customized to display the information they prioritize and in a visualization that they feel is appropriate for their patients.
Collaborative Goal Setting
Automate the delivery process
Due to limited appointment time, collaborative goal setting in the clinical environment is a challenge. To help tackle this problem we established recommended goals that are identified based on patient data.
Once goals have been selected the educational material previously identified by the physician is automatically queued in the print list.
Handy food list and recipes
If the patient requests additional information about a specific goal the goal breakdown can be displayed. This information is specific to the goal itself, the patient's current status, educational materials assigned to that goal, and the appropriate food list.
Physicians are currently automating certain processes themselves such as individually crafted goals, pre-printed educational material, and macros for common conversational topics being recorded in their EHR. CDS 2.0 would allow the physician to set up custom goals, load educational material, and port the appropriate information back to their EHR upon completion of the CDS 2.0 flow.
The repository of educational materials
Physicians lean heavily on external resources for patient education but often lack a centralized repository for those materials. CDS 2.0 provides the space for those resources, allows for the categorization of material, and delivers material directly to the patient.
CDS 2.0 takes a relational approach to education material to streamline the process of delivery, requiring less input from the physician during the appointment.
One-off note to warm handoff
CDS 2.0 provides a long-term record-keeping solution with patient goal data being stored within CDS while also providing a platform to efficiently update EHR fields with relevant data.
To provide the flexibility and address individual patient needs CDS 2.0 allows the customization of goals, selected educational material, and provides opportunities for the physician to add one-off notes and track internal-facing subjective evaluations
Upon reaching the nutrition focused portion of the patient consultation, the physician would launch CDS 2.0 from their EHR and progress from the patient Overview, Labs, Nutrition, Goal Setting, Education, and Notes. Only the Goal Setting and Notes screens require entries from the physician. The other screens would be for communication purposes and can be used at the physicians discretion. CDS 2.0 focuses on creating an environment where continued use leads to less overhead.
Guidelines for Further Research
Throughout the study we identified several key points that should be considered when planning further research specific to CDS 2.0.
That it's already connected to the EHR would be super helpful, I think that would be my selling point."
A cornerstone of CDS 2.0 should be saving time and EHR compatibility is
a foundational component necessary to gain entry into the physician workflow.
I think they could absolutely…a nurse could handle this."
Other forms of the delegation were mentioned including nurse-delivered counseling and the use of Community Health Workers in data collection.
People were paging…or were calling, or finding people in the hallway and saying ‘hey’, that was usually the easiest way of getting something done.”
There is potential for CDS 2.0 to facilitate warmer referrals from physician to physician or physician to registered dietician.
Some physicians expressed skepticism over self-reported data being used for treating conditions. With telemedicine rising in popularity self-reported data will become more common but addressing this challenge early might ease this transition.
Language, Low Literacy
Language barriers are often a challenge and may require the help of alternative assets such as Community Health Workers for patient onboarding. Much of the target demographic is low literacy and may require additional consideration specific to onboarding, data collection, and pacing.
Presentation, Data Collection
Accessibility will need to be considered in regard to visualization in the physician facing application. For data collection, accessibility will play a larger role in the design and implementation of CDS 2.0.
Transform conflicts to opportunities
The healthcare system is comprised of extremely complex workflows. There is so much nitty-gritty that we may not be able to solve at the moment. Sometimes it was easily get "sidetracked" on the pain points due to the systemic issue given they significantly impede care providers' willingness to adopt a new tool, such as providers facing time pressure to do more things in less time. We decided to grasp the nettle to take this as an opportunity to provide creative solutions not only to help the primary care providers to adopt new technologies but also to improve the systemic issue by striving to automate the heavy-lifting tasks.
Articulate design decisions
Articulating the design decisions is particularly important to gain valuable input from the team. Sometimes the thought process behind each design decision involves intuition that makes you think this feels right, but it's hard to impart what drives it. The ability to explain the intention of the design solution to help the team to understand and provide feedback is more critical than just to create pixel-perfect solutions.
Keep product documentation
Documentation serves as the backbone of a successful product. Especially when a multitude of changes in thoughts, solutions, and design decisions got piled up, it's difficult to trace back what are the concepts behind. Keeping proper documentation will enhance the design process and communication within the team.