Helping providers customize, enter, and review structured data over time in a hectic healthcare setting.

Background

Practice Fusion is the #1 cloud-based electronic health record platform for doctors and patients, free to use and set-up. Their platform combines an elegant web-interface with a simplistic mobile application, as well as a patient portal. They serve small and medium practices across all specialties and a variety of health care environments.

As a senior interaction designer with Practice Fusion, I owned design for the clinical and charting teams, working in the desktop and mobile environment. My projects included a complete overhaul of note writing, patient list management, allergies, diagnoses, medications, vitals, and flow sheets in the transition from a Flash-based system to HTML5

Beyond these responsibilities, I performed research and requirements gathering, did extensive work in defining patterns across the EHR, mentored individuals desiring to move into the design realm, and explored dashboard designs for high-risk patient populations among other future-looking projects.

The problem

Doctors and their care teams have very little time during the day, and especially during a patient visit. While they are inundated with information, it is hard to make sense of this information or get access to it when needed. Doctors have historically relied on the ease of paper for data entry and display for this patient data. While not always optimized for later review and by no means intelligent, paper is easy to enter into, flexible in the process of review and entry, and reliable. It is always at hand.

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For the last four or five patient visits, a doctor may have zero minutes free time

In the transition to Electronic Health Record (EHR) systems, providers have suffered in their ability to find systems that are fast enough and flexible enough to keep up with their needs. EHRs may be slow to perform or crash, and are overly burdened by poor design choices, governmental regulations, and a one-size-fits all for provider and specialty. What was once contained in a quickly accessible bundle of paper may now spread across multiple hard-to-find screens.

The challenge of flow sheets

One particularly tricky problem for providers dealing with EHR systems is the entry and review of data over time. Traditionally, this data was captured on paper in a variety of what are termed “flow sheets”, tabular and graphical displays of data over time which vary depending on patient need and provider specialty.

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While messy, doctors have a lot of flexibility with paper flow sheets, entering data when and how they need to

I was tasked with the challenge of researching and designing the entry and review of this data into EHR flow sheets, defining a customizable solution to meet multiple provider needs across practice size, specialty, and provider needs. This was a request we had heard from a huge number of providers using Practice Fusion – and one the company was willing to invest a great deal of time into.

So, I had to figure out what we were going to do.

Research and requirement gathering

In an effort to appropriately design and deliver the flow sheet offering, I performed a variety of research with stakeholders and users, and investigated best practices and needs with a variety of user experience research methods.

  • Sit down with project stakeholders: I began by getting some initial business goals and timelines from my product manager, identifying some initial thoughts around timelines, assumptions, goals, and scope. In this process I helped carve out some time for research and design, including iteration and potential methodology.
  • Evaluating previous thought work: Flow sheets being a critical part of the provider workflow, a number of previous efforts around flow sheets designs had been undertaken by various Practice Fusion designers and stakeholders. I reviewed these
  • Literature review: In addition to reviewing internal wiki documents, by simply googling up flow sheets and table design articles, I was able to take away some key insights around how providers experience using flow sheets today in the paper world.
You can learn a lot with a little googling

You can learn a lot with a little googling

  • Competitive analysis: I reviewed 5 EHR systems for their paradigms in data entry and execution of flow sheets, trying to understand where they succeed and where we might capitalize where they have failed. In addition I sat with our onsite clinical expert to get his take on how these systems succeed or fail in their entry and display of data.
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Investigating other EHR systems was a great way to mine a better understanding of the need for flow sheets

  • Provider interviews: I spoke with a number of providers in varying specialties about their experience using flow sheets today, digging deeply into their workflow and needs for data entry and display.
  • Heuristic evaluation: I evaluated the EHR’s current minimal interface for entering and viewing vitals and growth charts data over time, as well as current ability to customize the interface around data display, writing up top findings and to better understand how we would need to migrate users of this interface to the more advanced flow sheets development.
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Vitals data was traditionally entered in a form, while static growth charts were displayed. Now these needed to be transitioned into flow sheets.

  • Sketching sessions: I sat with design and key project stakeholders to do a number of preliminary brainstorming sessions, generating a lot of sketches quickly to get multiple ideas on the table and discuss risks and possibilities around the project as a whole.

What one colleague said on my research style:

In addition to being a great interaction designer, Jerry:
– Climbs steep learning curves with ease
– Works the full UX stack, from the information architecture down to the microinteractions
– Thinks in terms of systems and patterns
– Has the technical chops to sweat the details
– Is adaptable and unflappable
– Knows how to interview users to get at their core wants and needs

I’d jump at the chance to work with Jerry again.

Rick BondRick Bond, Director of Design Research at Uber
Rick managed Gerald indirectly at Practice Fusion

The design

  • Multiple design files for implications across the system: After some initial independent sketching I took to Fireworks to design multiple interface elements based around our goals. These flows were designed as user stories to show a user’s interaction in creating and editing flow sheets, attaching them to a context, entering data, and reviewing that data in various ways. Because this work spanned across the interface and involved a high amount of customization, I broke the designs across six files that showed the main flows, including:
Create flow sheets, add rows, include observations, and attach to encounters and various providers

Create flow sheets, add rows, include observations, and attach to encounters and various providers

See other flow sheets created by the community and create a copy

See other flow sheets created by the community and create a copies, edit, report, etc.

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Add or customize flow sheets in an encounter and on the face sheet per provider or patient

Create and add flow sheets to an encounter on the fly with structured or unstructured data values

Edit flow sheets on the fly and customize for a given patient, adjusting data shown

Viewing and editing information in a flow sheet for a patient

View and edit information in a flow sheet for a patient, sorting, filtering, traversing time

Printing views of complex tabular data that may span pages

Printing views of complex tabular data that may span pages and need call out

  • Utilizing existing patterns: In the process of designing I was utilizing existing patterns and pushing on existing patterns where they could not support the optimal user experience. This led to weekly reviews with our core patterns team to help define the visual and interaction evolution of the product.
  • Reviewing and testing with users: Through rapid-fire usability testing and provider interviews showing the designs, we were able to catch provider feedback early and refine based on confusions and struggles in task completion.
  • Weekly reviews with high-level project stakeholders: Marketing, clinical advsiors, engineering, and project managers were briefed weekly, reviewing designs
  • Multiple reviews with developers: After a two-hour initial overview of all the designs, and a Q/A period, there were a number of follow up and 1:1 discussions with various engineers around some of the more tricky problems.

What another colleague said about my design style:

Jerry is the kind of designer you can throw into a new domain, ask to extend and improve the design system and he will do it all with a great attitude and deliver really solid design solutions. He’s got great design instincts, works well not only with other designers but with developers. He’s dedicated and trustworthy, able to take a design system and run with it, but also makes a point of checking in to make sure everyone’s on the same page. He’s a delight to work with, and I hope to have the pleasure of working with him again in the future.

Stefan KlocekStefan Klocek, UX lead – Google
Stefan managed Gerald indirectly at Practice Fusion

Putting on the polish

While working hand in hand with developers at every turn, before they could really dig in some final polish was needed.

  • Basic redlining: Working with our dedicated visual designer, I helped develop red lines calling out alignment, coloration, spacing, and more visual-focused spec.
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Detailed and clear red lines to prevent engineers from having to dig too deeply

  • Finalizing responsiveness: As Practice Fusion scales across multiple browser types and tablets, we dug deep into needs across these devices and made sure the specs were complete across the relevant responsive breakpoints.

Image result for practice fusion flowsheets

  • Interaction notes: Detailed interaction notes were shown on each page for various elements indicating how things should work when not obvious.
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Interactions notes define hidden behavior and additional states not warranting a full page

  • Edge states were defined around error states, loading states, load order, blank states, truncation, and more.
  • Iconography and graphic assets were created and exported where needed to keep the devs running smoothly
  • Iteration, paring back from future to MVP, and story creation: After developing a full-future file, I pared back to something deliverable in stages. Working with the project manager, we created the stories and then pointed with engineers to better understand work needed and staging of delivery

Conclusion

Flow sheets is now available to all practices utilizing Practice Fusion and continues to be iterated on to provider a faster and cleaner review and entry of data for patients over time.

It was a rewarding challenge to work with the talented engineering team at Practice Fusion to deliver such a complex and important piece of functionality.