Addressing the "Black Hole" of Low Back Pain Care With Clinical Decision Support: User-Centered Design and Initial...

Low back pain (LBP) is a highly prevalent problem causing substantial personal and societal burden. Although there are specific types of LBP, each with evidence-based treatment recommendations, most patients receive a nonspecific diagnosis that does not facilitate evidence-based and individualized care.

We designed, developed, and initially tested the usability of a LBP diagnosis and treatment decision support tool based on the available evidence for use by clinicians who treat LBP, with an initial focus on chiropractic care.

Our 3-step user-centered design approach consisted of identifying clinical requirements through the analysis of evidence reviews, iteratively identifying task-based user requirements and developing a working web-based prototype, and evaluating usability through scenario-based interviews and the System Usability Scale.

The 5 participating users had an average of 18.5 years of practicing chiropractic medicine. Clinical requirements included 44 patient interview and examination items. Of these, 13 interview items were enabled for all patients and 13 were enabled conditional on other input items. One examination item was enabled for all patients and 16 were enabled conditional on other items. One item was a synthesis of interview and examination items. These items provided evidence of 12 possible working diagnoses of which 3 were macrodiagnoses and 9 were microdiagnoses. Each diagnosis had relevant treatment recommendations and corresponding patient educational materials. User requirements focused on tasks related to inputting data, and reviewing and selecting working diagnoses, treatments, and patient education. User input led to key refinements in the design, such as organizing the input questions by microdiagnosis, adding a patient summary screen that persists during data input and when reviewing output, adding more information buttons and graphics to input questions, and providing traceability by highlighting the input items used by the clinical logic to suggest a working diagnosis. Users believed that it would be important to have the tool accessible from within an electronic health record for adoption within their workflows. The System Usability Scale score for the prototype was 84.75 (range: 67.5-95), considered as the top 10th percentile. Users believed that the tool was easy to use although it would require training and practice on the clinical content to use it effectively. With such training and practice, users believed that it would improve care and shed light on the "black hole" of LBP diagnosis and treatment.

Our systematic process of defining clinical requirements and eliciting user requirements to inform a clinician-facing decision support tool produced a prototype application that was viewed positively and with enthusiasm by clinical users. With further planned development, this tool has the potential to guide clinical evaluation, inform more specific diagnosis, and encourage patient education and individualized treatment planning for patients with LBP through the application of evidence at the point of care.