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The Employment of an Iterative Design Process to Develop a Pulmonary Graphical Display

Affiliations of the authors: Medical Informatics, University of Utah, Salt Lake City, Utah (SBW); Architecture, University of Utah, Salt Lake City, Utah (JA); Anesthesiology, University of Utah, Salt Lake City, Utah (NS, DW); Cognitive Psychology, University of Utah, Salt Lake City, Utah (FD); Department of Anesthesiology, University of California, San Diego, and the San Diego Center for Patient Safety at the VA San Diego Medical Center, La Jolla, California (MBW).

Correspondence and reprints: S. Blaker Wachter, University of Utah, Department of Anesthesiology, 3C444 SOM, 30 North 1900 East, Salt Lake City, UT 84132-2304; e-mail: <blake{at}relia.net>.

Received for publication: 08/16/02; accepted for publication: 01/13/03.

Objective: Data representations on today's medical monitors need to be improved to advance clinical awareness and prevent data vigilance errors. Simply building graphical displays does not ensure an improvement in clinical performance because displays have to be consistent with the user's clinical processes and mental models. In this report, the development of an original pulmonary graphical display for anesthesia is used as an example to show an iterative design process with built-in usability testing.

Design: The process reported here is rapid, inexpensive, and requires a minimal number of subjects per development cycle. Three paper-based tests evaluated the anatomic, variable mapping, and graphical diagnostic meaning of the pulmonary display.

Measurements: A confusion matrix compared the designer's intended answer with the subject's chosen answer. Considering deviations off the diagonal of the confusion matrix as design weaknesses, the pulmonary display was modified and retested. The iterative cycle continued until the anatomic and variable mapping cumulative test scores for a chosen design scored above 90% and the graphical diagnostic meaning test scored above 75%.

Results: The iterative development test resulted in five design iterations. The final graphical pulmonary display improved the overall intuitiveness by 18%. The display was tested in three categories: anatomic features, variable mapping, and diagnostic accuracy. The anatomic intuitiveness increased by 25%, variable mapping intuitiveness increased by 34%, and diagnostic accuracy decreased slightly by 4%.

Conclusion: With this rapid iterative development process, an intuitive graphical display can be developed inexpensively prior to formal testing in an experimental setting.

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