Investigating Information Visualization to Combat Information Overload in Electronic Health Records: Protocol for a Randomized Controlled Trial

Abstract

Background: Electronic health records (EHRs) have been linked to information overload, which can lead to cognitive fatigue, a precursor to burnout. This can cause health care providers to miss critical information and make clinical errors, leading to delays in care delivery. This challenge is particularly pronounced in medical intensive care units (ICUs), where patients are critically ill and their EHRs contain extensive and complex data.

Objective: We propose to study the effect of an information visualization dashboard on ICU providers' cognitive fatigue in 4 major US medical centers. In this randomized controlled trial, we will compare 2 leading EHRs with a visualization dashboard-based EHR called AWARE.

Methods: This crossover randomized trial will collect physiological and objective data using a screen-mounted eye-tracking device to assess cognitive fatigue among ICU providers. The study will involve 120 ICU providers from 4 US medical centers, with each site using its institutional EHR as the control and the AWARE EHR as the intervention. Participants will be randomly assigned to use either their institutional EHR or the AWARE EHR first, followed by the other EHR, with the order of EHR use and patient case order randomized by the study team. The AWARE tool is designed to integrate within an existing EHR system and provides clinical support tools, such as the ability to trend data points from body systems at a glance. Data analysis will include eye-tracking metrics, performance measures, and validated surveys to evaluate EHR usability and its impact on clinical decision-making. Primary outcomes include the number of cognitive fatigue instances per patient case, time to complete each case, overall usability of the session, number of mouse clicks per case, provider performance scores from questions asked during each patient case, and perceived usability of each EHR. Secondary outcomes include the number of eye fixations per patient case and perceived workload of each EHR.

Results: This EHR usability study was funded in 2021 and initiated in 2022, with a completion date of 2025. Data collection began in August 2023. As of now, 3 of the 4 study sites have completed data collection, with a total of 113 completed sessions thus far. Data collection is ongoing at the fourth site. Preliminary analysis is ongoing, and we expect to begin publishing results in late 2025.

Conclusions: Findings from this research may inform improvements in EHR interface design and usability, which may enhance provider performance, streamline care delivery, and improve patient safety outcomes.

Trial registration: ClinicalTrials.gov NCT05937646; https://clinicaltrials.gov/study/NCT05937646.

International registered report identifier (irrid): DERR1-10.2196/74247.

Keywords: EHR usability; electronic health records; eye-tracking; information overload; information visualization, cognitive fatigue.

Figure 1

Process map detailing the study steps from site enrollment to the start of the usability session.

Figure 2

Process map detailing the usability session for participants in both control and intervention groups. EHR: electronic health record; ICU: intensive care unit; NASA-TLX: National Aeronautics and Space Administration task load index; SUS: system usability scale.

Figure 3

A screenshot of the AWARE patient interface. Each rectangle represents a different system, indicated by that system’s icon (7 in total). Yellow coloring indicates that a value within a system is out of range, while red coloring indicates that a value is significantly out of range.

Figure 4

The respiratory system overview within AWARE. Trends are displayed for relevant vital signs and labs, along with medication administration instances along the bottom.