Review
Dashboards for improving patient care: Review of the literature

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Highlights

  • There is heterogeneity in the setting where dashboards are used.

  • There is heterogeneity in the design of dashboards and users targeted.

  • Dashboard use may be associated with improved outcomes in some contexts.

  • It is unclear what dashboard characteristics are related to improved outcomes.

Abstract

Aim

This review aimed to provide a comprehensive overview of the current state of evidence for the use of clinical and quality dashboards in health care environments.

Methods

A literature search was performed for the dates 1996–2012 on CINAHL, Medline, Embase, Cochrane Library, PsychInfo, Science Direct and ACM Digital Library. A citation search and a hand search of relevant papers were also conducted.

Results

One hundred and twenty two full text papers were retrieved of which 11 were included in the review. There was considerable heterogeneity in implementation setting, dashboard users and indicators used. There was evidence that in contexts where dashboards were easily accessible to clinicians (such as in the form of a screen saver) their use was associated with improved care processes and patient outcomes.

Conclusion

There is some evidence that implementing clinical and/or quality dashboards that provide immediate access to information for clinicians can improve adherence to quality guidelines and may help improve patient outcomes. However, further high quality detailed research studies need to be conducted to obtain evidence of their efficacy and establish guidelines for their design.

Introduction

Dashboards are a tool developed in the business sector, where they were initially introduced to summarize and integrate key performance information across an organization into a visual display as a way of informing operational decision making [1]. Originally derived from the concept of balanced scorecards (which are internally focused and look at current organizational performance), quality dashboards provide information on standardized performance metrics at a unit or organizational level to leaders, to assist with operational decision making [1]. A clinical dashboard is designed to “provide clinicians with the relevant and timely information they need to inform daily decisions that improve the quality of patient care. It enables easy access to multiple sources of data being captured locally, in a visual, concise and usable format” [2]. The key characteristics of quality and clinical dashboards, which separate them from computerized decision support systems (CDSS) or data provided by an electronic medical record (EMR) system include (a) the provision of summary data on performance measured against metrics (often related to quality of care or productivity) and (b) the use of data visualization techniques (such as graphs) to provide feedback to leaders or individual clinicians. With the introduction of Health Information Technology (HIT) the feedback provided by quality and clinical dashboards can be as near to ‘real time’ as possible; this is in contrast to more traditional methods of feedback on performance which often give data back to a provider or group days or weeks after an event has taken place [3].

Increasingly, health care organizations are introducing dashboards as a way of measuring and improving the quality of care provided by their organizations. For example, in the UK a ‘quality dashboard’ is being developed by the Department of Health for England and Wales to provide a measure of National Health Service (NHS) Trust (provider) performance, including information about the number of registered nurses per bed, doctor-to-bed ratio, staff and patient survey results, hospital acquired infection rates and mortality ratios [4]. This information will then be used by commissioners (purchasers) of healthcare to inform their decision making about the quality and outcomes of the services they commission. More generally, three recent reports have called for comprehensive, real time HIT to be integrated into clinical and management processes in NHS Trusts in order to improve quality of care and patient safety [5], [6], [7]. In the United States (US), the Hospital Compare website (http://www.medicare.gov/hospitalcompare/search.html) provides information about the quality of care at over 4000 hospitals receiving public funding to help consumers make decisions about where to get healthcare and to encourage hospitals to improve the quality of care that they deliver. In Canada online clinical and financial dashboards have been employed by national, provincial, regional and hospital organizations to report on indicators of health system performance such as mortality and birth rates, admission and readmission rates, emergency room visits and wait times (too illustrate a few) [8], [9], [10], [11], [12]. In 2013 the Canadian Institute of Health Information (CIHI), a national body whose partners include Health Canada, Statistics Canada and ministries of health from each of the provinces and territories, began working on a project aimed at strengthening its pan-Canadian reporting on healthcare system performance. This national effort emerged in response to a consultation process undertaken by CIHI with healthcare system managers from across Canada. Managers suggested that healthcare organizations are currently reporting on many healthcare system indicators and this has led to “indicator chaos”. CIHI's work is expected to lead to a more structured and coordinated a reporting system on indicators of health system performance for specific groups (e.g. Canadian citizens, provincial ministry of health policy makers, and regional health authorities and health care facilities executives and managers), and interactive web and business intelligence tools that will facilitate managerial and executive decision-making [8].

However, what is currently unclear is the impact that introducing quality and/or clinical dashboards have upon desired outcomes. Existing evidence evaluating the effect of introducing HIT systems such as Computerized Physician Order Entry (CPOE) highlight how unintended consequences can occur once such systems are introduced [13], [14], [15], [16], [17], [18], and the evidence base supporting the effectiveness of CDSS to improve patient outcomes is equivocal [19]. Similarly, the literature on the effects of using quality measures to improve performance at an organizational level highlights the problems that dashboards can introduce, such as incentivizing certain behaviors or outcomes at the expense of others. Consequences can include tunnel vision (i.e. only focusing on the aspects of performance that are measured, while at the same time displacing other important but unmeasured aspects of performance) and measurement fixation (an emphasis on meeting the target rather than the overarching purpose of care) [20], [21], [22]. Whilst the use of visual information can help reduce information overload and improve understanding of data and the ability to remember information [23], it is unclear how the different types of visual display used in dashboards may affect comprehension and decision making, although the way in which information is presented (e.g. icon displays vs. tables, pie charts and bar graphs) has been shown to impact on the accuracy of decisions taken by clinicians [24]. At a time when health care organizations are being encouraged to introduce dashboards in order to improve quality of care and patient safety, it is important to review the effect of quality and clinical dashboards on care processes and patient outcomes and to understand how variations in the design of dashboards impact their effectiveness.

This review of published literature was conducted to assess the current state of evidence for the use of clinical and quality dashboards in health care environments. The objectives of the review were to:

  • Evaluate outcomes (patient and care process) associated with the implementation of clinical and/or quality dashboards.

  • Identify if and how clinical and/or quality dashboards impact on clinician decision making and behavior.

  • Determine the most common design approaches to display information in dashboards.

Section snippets

Methods

We conducted a rapid review of literature related to quality and clinical dashboards. There is no consensus on the exact methods for conducting a rapid review, which is a “streamlined approach to synthesizing evidence in a timely manner” [25]. In this instance we wished to gain an overview of existing evidence in a newly developing field of enquiry, in order to provide consensus for future research and to respond to rapid developments in health system and policy development. Rapid reviews

Study selection

A total of 537 citations were identified through database searching and a further 11 through citation searching. After initial screening we identified 195 potentially relevant articles; of these 73 were excluded, 68 were conference abstracts with no full text available and 5 were inaccessible. 122 full text papers were retrieved for further screening of which 111 were excluded either because they were not about dashboards (n = 76) or did not contain any empirical data (n = 35), leaving 11 studies

Discussion

The aim of this review was to assess the current state of evidence for the use of clinical and quality dashboards in health care environments. As highlighted in the introduction, the use of clinical and quality dashboards, which aggregate metrics (such as performance or quality indicators) into a visualized format to provide feedback to clinicians and managers is increasing (7 of the 11 studies in this review have been published in the last 3 years). There has been much discussion of dashboards

Author contributions

All authors contributed to the conception of the review. RR led the design of the review, with input from all authors. EB, PD, GF, JF, SH, and ZWM reviewed the retrieved references, with RR acting as second reviewer. Papers were retrieved by RR, with assistance from EB, PD, and LC. RR reviewed the full text papers, with assistance from LC and GF for papers in French and German, with PG and DD acting as second reviewers. Data extraction and quality assessment was undertaken by RR and DD. DD led

Conflicts of interest

The authors have no competing interests.

Summary points

What is already known on the topic?

  • Quality and clinical dashboards provide summary data on performance measured against metrics (often related to quality of care or productivity) using data visualization techniques (such as graphs) to provide feedback to leaders or individual clinicians to inform care decisions at organizational, unit or individual patient level.

  • Introducing Health Information Technology such as dashboards can lead to

Acknowledgements

We would like to thank Johanna Westbrook and the members of the Nursing Informatics International Research Network (NIIRN) for their support in carrying out this work. The authors are part of the Nursing Informatics International Research Network (NIIRN) which is supported by an International Research Collaboration Grant from the University of Leeds, UK.

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