Pain Addiction Progress 2009-7

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Contents

Project Guide

SBIR Phase II Contract #HHSN271200900003C

ADB Contract No. N44-DA-9-2213

Title: Web Based Training for Pain Management Providers

PI: T. Bradley Tanner, MD

Monthly Progress Report #4 of 24

Reporting Period: 7/1/09 – 7/31/09

Project Period: 4/1/09 – 3/31/11

Pain and Addiction Project Framework

Overview

July was another productive month as we made preparations for our first usability test with the target audience scheduled for the end of summer. We continued to develop the website PainandAddictionTreatment.com's CME course content and user interface, completed drafts of several additional "Key Info" guides, and conducted an internal usability test of the user interface and functionality. Based on the results of the internal usability test, we further refined the website's interface and developed a new taxonomy system by which the Resources can be searched.

Progress During July 2009

Objective 1

Develop Skills Training Content

Courses: We started editing the three completed core courses ("Initial Assessment", "Initial Prescribing", "Ongoing Management") and started filling in additional fields for each page. The additional fields, FYI, Key Points, and Related Resources, support and supplement the learning experience. We also continued to abstract information from the more detailed "Key Info" guides for inclusion in the courses. Finally, we began writing content for the fourth core course, "Avoiding Diversion" and continued research on the remote, live standardized patient courses based on pain condition and type of substance use problem.

Resources: This month we focused on developing a new taxonomy system for use with the faceted (refinable) search of the several hundred Resources we have collected. Based on the unanimous perception that we had too many tags from which to choose, we added 9 additional categories with fewer tags under each category. See Appendix A for the revised taxonomy.


"Key Info" Guides: We completed two additional guides ("Evidence on Long Term Opioid Use" and "Prescription Drug Monitoring")and worked on the remaining two guides (Opioid Prescribing guidelines, Assessment Tools).

Objective 2

Build Supporting Functionality

Building and refining website functionality was a key focus this month as we responded to the results of our internal heuristic usability test described below. The following issues were addressed:

General

  • The course pages were converted from book page format to the "course content" type format to allow greater customization of the course pages.
  • The Reference and Related Resources sections of the course pages and key info guides were converted to expandable clicktips, allowing the reader to expand them or keep them hidden.
  • The dropdown menus were modified to reveal only the first level of courses and Key Info guides. This makes the dropdown menus less overwhelming to the user while still maintaining usefulness and functionality.
  • The font of the homepage, FAQ, and other blocks was increased throughout the site.
  • The color scheme of the site was changed using a color picker to preview site changes. After the new scheme was approved and tested, the CSS style sheet was adapted to permanently reflect the new colors.
  • The site was tested on IE 7. The site was configured so that all style sheets are merged so that the site performs better when viewed in IE 7.
  • The site was proof read for miscellaneous html errors that might interfere with the navigational boxes. All html errors were fixed. Additionally, margin issues were corrected.
  • A blog was added to the homepage to feature news and events related to the development of PainAndaddictionTreatment.com
  • A quiz module was researched and tested which may be useful in facilitating data management of pre- and post- tests.

Resources

  • After testing various methods of categorizing the resources in the resource center, a list of 13 categories was created and the terms used to tag the resources were reorganized to better support searching through the great number of resources in the resource center.
  • The date field was configured to show only the year a resource was published.
  • A Drupal View was created which displays search results alphabetically, shows an interactive fivestar rating of each resources, and allows registered users to add resources to favorites.
  • A "Pick a Screening Tool" section was started which will help guide physicians on how to both use the faceted search for finding screening tools, and to provide questions they should ask themselves about what they want in a screening tool.
  • The Guided Search box was moved to the top left of the Search Results to make it more visible so that users will be able to more readily narrow down search results.

CME courses

  • The functionality to support adding Key Points, Practice Tips, and FYI's was added to the CME courses and was formatted.

Objective 3

Evaluate Curriculum Content

  • Using an iterative review process, this month we sent the 2 additional completed key info guide drafts to the consultants with the most expertise in each area. A third guide on informed consent and patient agreements is being reviewed by consultant Nancy Weidemer.

Objective 4

Evaluate Interface Design (Usability)

  • We wrote usability questions for the first usability test (See Appendix B). Due to difficulties recruiting and scheduling staff during summer vacation months, we decided to conduct an internal usability test and reschedule the first test with the target audience for early September. This gave us the opportunity to discover bugs in the functionality of the website and obvious design problems as well as to test the usability questions. Three staff members acted as users for the internal usability test. Notes were taken and consolidated to generate a single list of findings. For example, a major finding was that the taxonomy system was overwhelming due to having too many tags to choose from in the main category. To resolve this, a new taxonomy system with more categories was created. We developed corresponding plans of action to resolve all of the issues identified and were able to address most of the issues already this month as described in Appendix C.

Objective 5

Obtain OMB clearance

No activity this month.

Objective 6

Conduct Summative Evaluation

Scheduled for year 2.

Objective 7

Disseminate Results

No activity

Work to be Performed in the Next Reporting Period

Objective 1

Develop Skills Training Content

Courses: We will finish adding the key points, resource, and other information to the first three of the core courses (Initial Assessment, Initial Prescribing, and Ongoing Monitoring) and finish creating mini-case scenarios to illustrate each step. We will also complete development of quiz questions and pre/post-tests.

Resources: We will continue to catalogue resources by applying "tags" to each resource in the data base using the new taxonomy.

Key Info Guides: We will complete the first drafts of the remaining guides (Opioid Prescribing and Assessments)and send them to expert consultants for review as they are completed.

Objective 2

Build Supporting Functionality

We will continue to address the remaining issues identified in the internal heuristic usability test.

General

  • Develop a simple guide for physicians detailing how to use the resource search tool to find the best screening or assessment tool for a particular purpose.
  • A "Recent News" section will be added to showcase changes in FDA regulations or recommendations from professional organizations, such as opioid prescribing guidelines, as well as new additions and developments to the site.
  • Breadcrumbs will be added to the search results so that users may modify their search results by taking away a search term.
  • The terms in the assessment tool section of the resource center will be simplified from the official names of each tool to the categories they belong to. This will make the scope of each term broader, allowing the user to select the substance or issue of interest, and then select the most appropriate tool. Screening tools will still be tagged with their name and acronym, and may be searched that way, as well.
  • The layout of the course and Key Info guides will be changed so that each course and each Key Info guide has their own section, allowing the user to concentrate at one course or guide at a time, and preventing the left navigation from becoming too overwhelming to the user.
  • The fivestar rating feature for resources will be styled so that five stars appear in a row, colored yellow according to the rating of each resource.

Resources

  • Develop the faceted search feature of the Resource Center so searches on a topic can be narrowed down by clicking tags related to the field of interest.
  • Develop a search tool for assessment tools which will rely on a system of tagging.
  • Improve the faceted search by incorporating the categories and terms we came up with in July into the resource center.

Objective 3

Evaluate Curriculum Content

Send remaining completed How to Guides and core courses to consultants for review as they are completed and revise according to feedback.

Objective 4

Evaluate Interface Design (Usability)

Refine assessment tool based on internal heuristic usability test results and recruit 9 participants for first usability test with the target audience scheduled for early September 2009.

Objective 5

Obtain OMB clearance

Develop the summative assessment to be included in the OMB clearance application.

Objective 6

Conduct Summative Evaluation

Develop the summative evaluation assessment tool for the summative evaluation that is scheduled for year 2 as described above. This assessment will be included in the OMB application.

Objective 7

Disseminate Results

We will submit an abstract for presentation to the American Academy of Pain Medicine (AAPM): 26th Annual Meeting San Antonio Texas based on Phase I formative analysis results.

Contact

Please feel free to contact me if you have any questions or concerns. I can be reached at (919) 960-8118 or tanner at clinicaltools dot com.

T. Bradley Tanner, MD (President, Clinical Tools, Inc.)


Appendix A: Taxonomy for Searching Resources

Categories:

  1. Evaluation
  2. Guidelines
  3. Mental Health and Other Comorbidities
  4. Opioids and Other Controlled Substances
  5. Patient Education
  6. Patient Management
  7. Population
  8. Prescribing
  9. Screening and Assessment Tools
  10. Specific Pain Diagnos
  11. Substance Use Problems
  12. Treatment
  13. Type of Pain
  14. Type of Resource

Example tags under a category:

  1. Evaluation
    1. assessment
    2. clinical forms
    3. consultation
    4. first visit
    5. patient interview
    6. patient monitoring
    7. patient selection
    8. risk stratification/triage
    9. screening
    10. urine testing

Appendix B: Internal Heuristic Usability Test Questions

July 2009 n=4 CTI staff

Home page:

  1. Before looking at the website, what would you think the website is about if you just saw the website name, PainandAddictionTreatment.com? Please open painandaddictiontreatment.com by typing it into your webbrowser and let us know when you see the website.
  2. [Ask immediately after they see the website] Who do you think the website is for?
  3. Please describe how you would find a CME course on how to avoid drug diversion (but don't leave the home page). [Note time to answer] [They could either click on the “Avoiding Diversion” link under CME Option #1 or they could click on the tab "Courses."]
  4. Please note that we have not designed the appearance of the home page yet, but whe have listed the information that will be included. Please spend a moment to look at the page without clicking. What questions arose for you as you looked at the website home page? (e.g., Is the information or purpose to be provided in each section clear to you?) I'm going to ask you about each section one by one:
  5. What do you think "Referral Resources" would offer? [do not explain at this point]
  6. What do you think "Key Info Guides" would offer? [do not explain at this point]
  7. What do you think is the purpose of "New forum topics"
  8. Would you read a forum discussion on this website? Participate?
  9. Please click around until you find how to post a new topic and tell me how you would do that. [Time response. They have to click on "more." If they click on the one topic already posted, they have to go back to the main page to start a new topic. There is no way to do it from within a discussion.]
  10. What do you think "Pain and Addiction Pub Med" would offer? [After they answer, explain, these links take you to abstracts from journal articles on the PubMed website.]
  11. Would you use the PubMed abstract links on this home page?
  12. What do you think is provided in the section "Recent FAQs"?
  13. Please use the FAQ section for a moment (click around it, exploring how it works and what is offered). Do you anticipate that you can ask a question of your own here? [If yes, ask how. Note any time delays, stop them after 30 seconds if they haven't found it. It is the first question under all questions. If you open it, it provides a Contact us link and says we will respond shortly.]
  14. What do you think a "Remote Standardized Patient" is?
  15. Please click on "Remote Standardized Patient" and skim the explanation. What questions if any do you have after reading this description of remote standardized patient?
  16. Is "Remote Standardized Patient" something that would interest you to use? Please return to the website home page.
  17. Please look again at the list of CME courses. In which course or courses do you think you would find information on Urinary Drug Testing? Patient Agreements? Treating Breakthrough Pain or Acute Pain in a patien on chronic opioid therapy? Prescription Drug Monitoring? Complying with Government Regulations for Prescribing Controlled Substances? the Benefit to Harm ration of prescribing
  18. Have you noticed green boxes appearing as you move your mouse around the page? Please comment on their usefulness.
  19. Which section would you be most likely to use coming across this webpage for the first time? Next most likely to use?

Course: “Initial Assessment”

  1. (Start from home page) Please find and open a CME course on "Initial Assessments." Please read the number at the end of the website url at the top of your web browser. (instruct as needed in how to find this: "Where it says "http://www.painandaddictiontreatment.com/node/ What is the number at the end? Note: It should say 466. If not, tell them to highlight the number and type 466 and hit enter.)
  2. Please go to the next page and say "Ok" when it opens. [Time this step] How did you go to the next page [note whether they used Next or left navigation]
  3. [Ask if they noticed the form of navigation they did not use]
  4. How many pages are in this course? [gets at whether they anticipate that if they click on some of the pages, there might be another layer of pages, which there is]
  5. Please click on Initial Assessment Tools. What do you think about this set up where there are pages that are at a lower level in the course outline and that you can't see them initially in the left navigation [need help asking this question more clearly]
  6. What do you think of the left navigation? (Is it clear to you how it works? What do you think of its appearance? Clarity? Do you think the space between pages is sufficient, for example, is it easy to discern that Introduction: Initiating Assessment is one page and Screen for Risk is the next page? What do you think of this system where the subordinate pages are not visible until you click on the higher order page?)
  7. Would you prefer, instead of the words "Back" and "Next" to have simply arrows? the title from the next or previous page?
  8. Please comment on 1) information provided or planned to be provided and 2) how the information is arranged
  9. Please start the course [Time this step. Note if they need help finding the "Start Course" button at the bottom right of the 2nd page]
  10. Glossary. Look at the word yyy which is double underlined. What do you think the double underline means? [If they don't get glossary, tell them.]
  11. Please move your mouse over the term yyy. Was that what you expected to happen?
  12. Plese click on the term misuse. Was that what you expected to happen?
  13. How do you feel about having a glossary? How do you feel about the way the glossary works?
  14. How do they feel about the Glossary - every time the word comes up vs. the first time on the page? Should they look like a link, that is a single underline in the same color as links? Please use the back button to return to the course
  15. Please go to the next page of this course. [How did you go there?]
  16. Please comment on the way the page is displayed (organization of its elements)
  17. Please find the Reference on xyz [Time this step. Note if they need help finding the "References" click tip at the bottom left of the page]. Was that what you expected to happen when you clicked on References? What do you think of this way of presenting references?
  18. How would you find links to websites on the topic of this page? [Time this step. Note if they need help finding the "Resources" click tip at the bottom left of the page, below References].
  19. Please click on the Resources link at the bottom of this page and view whatever interests you and return to this page. What do you think of this way of presenting resources?
  20. Please find a page in the course titled “Quiz 1” [note delays or the need to find it for them]
  21. After opening the page, please take the quiz. What do you think of this way of presenting quiz questions?
  22. In the left navigation, please read the title of the last page for this course.
  23. Please click on the page Stratification of Risk and look at the bottom of the page for Sample Cases at EAch Level of Risk. Please comment on this way of displaying case examples.
  24. Please click on Post test and answer the first question. Please comment on the setup of the questions and they way they work.

Key Info Guides

  1. Please return to the website home page. How did you do that?
  2. Please look at the Key Info guides, what do you think the differences might be between the CME courses on this website and the key info guides? [answer: CME credit given, Key info guide – more detailed info on those topics]
  3. Please open a guide with key information on government regulations on prescribing opioids. What is the number at the end of the url in the webbrowswer window at the top? [should be 555]
  4. We eventually might offer CME credit for reviewing the Key Info Guides for Point of Care Credit [Explain if necessary: AMA PRA Cagegory II credit for looking up information relevant to a particular patient's care.] Would you be likely to use the credits offered in this way?

Resources

  1. Please click on the Resources tab.
  2. Please look at the box labelled "Categories." Are all of these categories clear to you?
  3. What do you think the category Physician/Treatment Lcators would find? [explain it finds webpages for pain and or addiction providers or treatment centers] Do you prefer the term  locaters or finders?
  4. What do you think of the list of tags?
  5. How would you find a resource on both chronic pain and mental health?
  6. How would you find a list of all the podcasts [Time this response. Answer: scroll down to the bottom and click podcast'
  7. Please click on the category xxx[Lyla writing around 8 questions on rating, copying to Favirite Resources, use of faceted search, etc.

Home page again

  1. Please name all the ways to reach Courses and Key Info guides. [Explain the drop down menus from the tabs at the top if necessary.]
  2. What do you think of the dropdown menu (i.e. for "Courses" and "Key Info Guides")
  3. Now that you have a better feel for what is on this website, please comment on the use of the stethoscope image in the upper left. Can you suggest another image that you think would be more appropriate for this website?
  4. This website will train pain management providers in the interface of pain and addiction medicine. On a scale of one to ten, how completely do you feel that the planned elements of this website fulfill that mission?
  5. What, if anything, is missing from the website?

Appendix C: Report on Internal Heuristic Usability

PainandAddictionTreatment.com

Internal Heuristic Usability Test: July 20-22, 2009

Section 1: Home Page

Finding: Tabs (yellow with white text) difficult to read; banner color (pink) not attractive. Status: Changed to blue and burgandy with grey accents color scheme. Rollover and click tip background colors changed to match.

Finding: Two links on upper right do not have enough contrast (Account and Contact are blue text on blue background). Two links do not show an underline upon mouseover. Status: Contrast and underlines fixed.

Finding: Blue letters on selected tab difficult to see against red background Status: Changed background to grey for greater contrast.

Finding: Stethoscope image nearly identical to one found on another pain website and not highly relevant to the topic. Status: Image deleted Finding: Blog invitation was visible to all but only worked for administrators. Status: Changed invitation so it is only visible to administrators after login.

Finding: Blog formatting not attractive. Status: Added emphasis to headers to improve appearance

Finding: Links should be underlined in blue as is most common on the Internet Status: Changed underlines to blue

Finding: Resources list too long and difficult to read Status: Gave outline different size fonts according to level of outline to differentiate sections of the list from each other

Finding: Not enough space between FAQ questions Status: Added space

Finding: Font size too small for most of the home page Status: Home page font enlarged slightly.

Finding: Exclamation points after Create a Site make it seem like it's a highly important and exciting part of the website, when instead it is not high on needs analysis. It makes it seem like this is exciting and Courses are not. Status: Removed exclamation point from Create a Site.

Finding: Clicking on a glossary term brought up the term and its definition but also brought up a forum topic for the term "misuse." Status: Status: Fixed.

Finding: For Resources, glossary definitions are inserted after the term rather than being displayed as a link. Status: These bugs still needs to be fixed.

Section 2: CME Courses

Finding: Left navigation unclear: Needs to indent following the outline form so that subordinate pages in a book start several spaces to the right of the page above. Status: Completed

Finding: Some pages were italicized and need to be plain text. Status: Completed

Finding: Font too small and needs to be enlarged Status: Enlarged slightly and will test whether more is needed in usability test.

Finding: Course titles appear the same as page titles Status: Course title enlarged and put on blue background

Finding: Users can skip the second page of Course Information and go right to starting the course. Status: Solution being investigated using the Drupal content management system.

Finding: There is no link from the 2nd page of the course information to the first course page. There is a large link that returns to the course list. Status: Start course link added.

Finding: Certain topics seem to be in the wrong course or expected topics missing from a course. Status: “Deciding Whether to Select Opioids for Pain Treatment” moved from Initial Assessment course to Initial Prescribing course. Also, course titles changed to better reflect their content: Initial Prescribing changed to Initiating Pain Treatment, Ongoing Management changed to Ongoing Management of Pain Patients, Diversion changed to Avoiding Diversion and Other Management Challenges. 3. Topics that seem to belong in multiple courses, such as “Prescription Monitoring Programs,” will be repeated in each course with a slightly different slant for each course.

Finding: Glossary terms underlined which seems like a link Status: Made them a different text color, gray, instead

Finding: Glossary terms underlined every time they are used, which is distracting Status: Need to use no glossary code to hide them after their first appearance on a page.

Finding: Resources not showing up. Status: Corrected an error in the naming of the type of resource. They now show up.

Finding: Key Points, FYI, Practice tips all centered. Status: Corrected an error in the css so that the first two are aligned right

Finding: No space between Key Points and FYI and course content Status: Added padding added around these features.

Finding: Resource link not obvious at the bottom of the page Status: Created a box with colored background to match Key Points, FYI, and Practice Tips

Finding: The word “References” was repeated twice. Status: Removed second instance.

Finding: The terms Resources and References might get confused Status: Changed to “Related Resources” and will test in next usability test.

Finding: Too much space between References with p tags and too little without them. Status: Removed p tags in references; need to add a small space using css.

Finding: Having all the courses flow from one to the next on one navigation bar was confusing as to where one stops and one begins for some users. They would prefer having each course have its own navigation bar and once you got to the end of the course, it would bring you back to a selection page where you could choose (and formally enter) the next course you wanted to take. Status: Added space between pages and white space between courses. We will test whether further change is needed during usability

Finding: There is only a very small space between pages in the left navigation so that it is difficult to distinguish a page with a long title that wraps to more than one line from multiple pages. Status: More space was added between each page. Will test in usability test is this is sufficient.

Finding: Additional information box centered rather than on the right on this page: node 528 Status: These were moved to a FYI box with the formatting controlled at a more central level.

Finding: Tables on nodes 500 and 534 had no background color; table on 803 has a background color that does not match. Status: Need to add css class for table headers and backgrounds.

Finding: No underline in link inside FYI box on node 803 Status: fixed link

Section 3: Key Info Guides

Finding. Same findings for navigation as found for CME courses. Status: See CME above.

Finding: In some Key Info Guides the navigation bar changes from page to page – sometimes all the links are bold, sometimes just the one you’re on; sometimes the link moves a little when clicked (awkward) and sometimes it doesn’t Status: Fixed bolding problem. Other problem fixes are in progress.

Finding: Only a link is provided for the Related Resources rather than the annotation information. Status: This was changed to display the full information in Key Info Guides as well as CME courses.

Finding: User liked the FYI boxes from CME courses Status: Add FYI box to Key Info Guides

Section 4: Resources

Finding: An overwhelming number of tags Status: We have created more separate taxonomies and combined tags and categories into groups so that each taxonomy will have a shorter list of tags. This still needs to be transferred online.

Finding: Users can only select one tag and cannot narrow a search down further by applying another tag. Status: Tags placed within one taxonomy, so a search can now be modified by selecting a tag within a different taxonomy. The drawback is that you still can only select one tag within a single taxonomy. We will test this in usability to see if there is a need for more search functionality.

Finding: Resources rated as five stars were showing up on the Highest Rated Resources list as having a value of 0. Status: Changed programming to accurately display average rating.

Finding: Guided Search appears too low on the page and is easily missed Status: Moved this up higher on the page, above Highest Rated Resources and Latest Resources. The latter two ideally would be displayed as expandable. click tips with only the titles visible initially.

Finding: Displaying a default month of January for all dates when there was no month Status: Hid all date information other than year

Finding: Too many subtypes of assessments will overwhelm the novice user Status: Removed brief and extended subtypes of assessments.

Finding: ASSIST is in the glossary (we don’t even have it as an assessment tool option on the website) but NIDA-Modified ASSIST is not. Status: Changed to NIDA Modified ASSIST

Finding: Latest Resources font relatively larger than other text Status: Changed to match other text on the page.

Section 5: Forum

Finding: There is no way to post a new topic once you are in a particular forum discussion topic. Status: Need to add breadcrumbs at the top of the page so that users can get back to the main forum page.

Other Progress Reports

Pain Addiction Progress Reports

Phase I Pain Addiction Progress • April 2009 • May 2009 • June 2009 • July 2009 • August 2009 • September 2009 • October 2009 • November 2009 • December 2009 • January 2010 • February 2010 • March 20010

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