This entry is part 17 of 43 in the series Words

When using a point-and-click medical charting application (of which there are a zillion, and I think I’ve used maybe a half-zillion) there are many designs, but I’ve recently realized there is a way to divide them into two types. There are one-layer charting apps and two-layer charting apps. I’m not talking about computer layers, I’m talking about conceptual layers.Layers Icon

In a one-conceptual-layer app, you click on a word to instantiate it. For example, if charting about someone’s tonsils, and you click on the word

Tonsillar Exudate

then that means that there is exudate on the tonsils. Conceptually, it’s a one-step process; there is only one layer of cognition needed to check items on the page. You click on the word to validate it. If you click on Tonsillar Exudate, there are tonsillar exudates.

In a two-conceptual layer app, you might have to click on a checkbox next to the word. For example, you might see:

 A   N
[ ] [ ] Tonsillar Exudate

You have to check the box for A (Abnormal) or the box for N (Normal). This requires a two-step, or two-layer, mental process. First, you have to find the term Tonsillar Exudate. Then you have to think” “What does ‘Normal’ mean in the context of Tonsillar Exudate? That means no Tonsillar Exudate. So I need to check ‘A’ for Abnormal since there is Tonsillar Exudate.”

I suppose you can argue that this is more than two steps, and likely you’re right. But for the purposes of simplifying the argument, I picked “one-layer” and “two-layer” even if the “two-layer” strategy may actually require several layers of cognition.T-sheet Sample


From an ease of use perspective, from an efficiency perspective, and from an error-prevention perspective, a one-layer charting system is quite superior to a two-layer charting system.

An example of a highly-successful mostly one-layer process is the T-system, available in both paper and electronic versions. The T-system offers two options for each item. First, on paper, if you circle Tonsillar Exudate or, on the computer, left-click  Tonsillar Exudate, that means it’s true. So, check next to, circle or click on Tonsillar Exudate, and this means that the patient does have tonsillar exudates. Second, if you draw a backslash through Tonsillar Exudate that means there is no tonsillar exudate.

An example of a successful two-layer process is DocuTAP.DocuTAP

If you’re looking at point-and-click charting applications, you may want to look carefully at whether charting is a one-layer or two-layer process. All other things being equal (and they’re usually not!) a one-layer process will be more efficient for your practitioners, cause less error, and make them happier.

And if you are a charting vendor with a two-step process, you should consider a revision to make it a one-step process. Even if your charting system is good, making it a one-layer system would likely improve it.

For point-and-click medical charting systems, simpler is better, at least in terms of the number of cognitive processing layers.

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This entry was posted by kconover on Wednesday, February 8th, 2012 at 2:50 pm and is filed under Tutorials . You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.

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