International Journal of Medical Informatics
Acceptance and cognitive load in a clinical setting of a novel device allowing natural real-time data acquisition
Introduction
During the past few years, and because of the increasing availability of commercial systems, health care has been facing an accelerating rate of computerization. The computer patient record (CPR) is usually considered as necessary to sustain health professionals in their daily tasks [1], mostly by providing a better access to information, to improve patient safety in order entry and to help getting a higher efficiency when the available resources are used. In this computerization process, the real-time acquisition of structured clinical data at the point of care remains a true challenge [2]. To improve real-time data acquisition, many elements must be considered. Among them, devices and technologies directly used for data acquisition are crucial. The mouse-keyboard paradigm appears to be poorly adapted in many clinical settings, mostly because of size, mobility, and the context where data acquisition occurs. Several alternatives, such as voice or handwriting recognition, have been tested and are used in some settings. However, the digital pen technology appears to us to be the first real commercial alternative to the traditional computer-screen-keyboard-mouse paradigm. The study about the digital pen and paper (DP&P) system was conducted in this perspective. The DP&P solution provided by Hewlett-Packard Corp is a handwriting device for semi-structured and structured data acquisition that can be integrated within an existing computer-based patient record. The DP&P allows capturing written data without any interaction with a traditional computer, just using a pen and paper printed with a special pattern. It appears to be a very natural device for data acquisition. Its low weight allows an astonishing mobility when compared with traditional devices such as PDA or any portable computer.
The assessment of a new technology, or a new paradigm, goes further than only evaluating its physical or direct characteristics. It requires to be tested in real conditions and its usability must be assessed [3].
According to the literature, it seems that more than half of the projects involving computerization of care processes do fail, even if they are technically sound [4]. Various studies have highlighted that organizational issues count partly as causes of failures [5], [6], and that behavioral factors have a great influence on implementation success [7]. A complete assessment of a technology shall include its technical characteristics (such as integrability, robustness, acquisition reliability), the user–device interactions (acceptance/satisfaction, usability), and the analysis of surrounding phenomena [8], such as its suitability within the social cooperative context of information acquisition and its condition of use [9].
In order to increase the reliability of our assessment, we designed a two-phase interventional study in two different clinical settings. The two clinical settings were designed to focus respectively on acceptance and usability of the technology for one, and the reliability of data acquisition for the other.
The acceptance and usability evaluation of our study included both quantitative and qualitative investigations. The observations performed before and during the intervention provided a crisp picture of the contexts, the concrete use of the technology, and allowed to identify points to investigate in a more specific questionnaire survey associated with team discussions after the intervention. In addition, these observations drawn our attention on additional burden induced by some characteristics of the technology. The ability to identify more precisely these characteristics, their perception and the interferences caused during human–machine interactions has been important to spotlight the post-intervention part of the study.
This paper focuses on the evaluation of usability and user acceptance, and more specifically on identifying cognitive burden perceived by the users of a new technology presented as very well accepted. The technological assessment of this new device and the report of a complete evaluation of the reliability of data acquisition are out of the scope of this paper and are available separately [10].
Section snippets
Background
The Geneva University Hospitals (HUG) is a consortium of hospitals, comprising more than 2000 beds, 5000 care providers, over 45,000 admissions and 450,000 outpatients’ visits each year. It covers the whole range of in- and outpatient care, from primary to tertiary facilities. The HUG is the major public healthcare facility in the Geneva region and the near France. Therefore, beside its teaching and research role, it has to provide the complete range of care to the general population, including
Digital pen and paper (DP&P) technology
The DP&P technology combines two elements, a paper and a pen. The paper is characterized by the use of a microdots pattern that can be printed on standard paper, including recycled paper. The pen contains a small camera, a memory, several captors, and a communication unit. The consequence of the embedded technology is a bigger and somewhat bulkier pen than usual. The version of the pen used for this study, the Digital Pen 200 weights near to 50 g, measures 17.5 mm length and about 28 mm diameter.
Results
Thirty-three nurses were involved in triage during this period. They filled out 1183 triage forms. All patients admitted in the adult ER during the trial have been covered. The server received more than 80% of the digitalized forms. Among the forms received by the server, 87% were complete (human comparison with a copy of the original). Considering the 13% non-digitalized forms, approximately half of them were not transferred because they were not validated by users, which means users did not
Discussion
As emphasized in distributed cognition models, human computer interactions occur in most cases in a complex technological and social environment [11]. The human cognition is always embedded in an intricate sociocultural context, which affects him in return [12]. In order to understand how these interactions occur, and how cognition is affected, we have to understand and study the context of work, and link its characteristics to the other results collected. Ethnographically informed observations
Conclusion
Contextual inquiries are used to understand how users work in their real environment. These methods can reveal unexpected effects and requirements. During such investigations, the uncovered problems are not only informational and related directly to the technology, but may have a great influence on how the technology will be used and experienced by users [21]. As highlighted by Kuniavsky [21], the important information to collect during contextual inquiries concerns the tools and their use, the
Acknowledgements
This work has been supported by the Swiss National Science Foundation 632-066041, and the University Hospital of Geneva, PRD 03-I-05.
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