USABILITY TESTING OF “INFORMEDTOGETHER”, A WEB-BASED DECISION AID TO FACILITATE SHARED ADVANCE DIRECTIVE PLANNING FOR SEVERE COPD

Purpose: To examine the usability of InformedTogether, a web based decision aid for shared advance directive planning between chronic obstructive pulmonary disease (COPD) patients and their doctors. The decision aid uses mathematical modeling to provide prognostic estimates for intubation versus no intubation.

Method: We conducted an observational study of 16 COPD patients and 13 doctors at two outpatient clinics with diverse ethnic and socioeconomic populations. Data included observations of patients and doctors using the decision aid on tablet or laptop computers and semi-structured interviews. Patients attending a pulmonary clinic or pulmonary rehabilitation were shown the decision aid (including an icon array with prognostic estimates) by a researcher acting as the clinician. Eight pulmonary doctors were observed using the decision aid and asked to “think aloud”, verbalizing their thoughts as they used InformedTogether. Five pulmonary doctors were directly observed while using the decision aid with a standardized patient. All usability testing was followed by interviews to elicit feedback. A thematic analysis was implemented to explore key issues related to decision aid usability.

Result: Patients and clinicians found InformedTogether acceptable, with most stating they would recommend doctors use the decision aid with COPD patients. Patients and clinicians also found the decision aid comprehensible. Limitations identified included patients’ understanding of the icon array and patients’ knowledge of advance directives. Four clinicians had concerns about the length of the decision aid and seven thought it may cause nervousness among patients. Minor usability problems related to content, links, layout, and consistency, which made the decision aid more difficult to navigate. Corresponding ‘fixes’ were outlined. The time needed to use the decision aid ranged from 15-20 minutes. Participants had suggestions for additional content including information about quality of life. In testing with standardized patients, clinicians requested to have the decision aid on their desktop and linked to the electronic health record.

Conclusion: InformedTogether was found acceptable by COPD patients and their doctors. Participants endorsed using the decision aid for shared advance directive planning for severe COPD, although they desired more information about quality of life implications of each advance directive. The design must optimize comprehensibility and feasibility of integration into clinical workflow, including revising the presentation of statistical information, shortening the decision aid, and integration into the electronic health record.