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System overview
SLE-T2T web-based system was developed. The processing of the system takes place on the user’s computer, and, since no data is stored, the architecture of this decision support system is essentially composed of: (1) an input scheme consisting in the diverse set of index and scores existing for the measurement of SLE disease activity (cSLEDAI-2K, SLEDAI-2K, PGA score) as well as the used medication; (2) a rule-based interface that collects and processes patients’ data and (3) an output dashboard with the generated set of recommendations tailored for the patients’ clinical state and aiming to reach a pre-established target of treatment, based on the T2T strategy. Figures 1 and 2 depict a comprehensive view of the system architecture.
Overview of SLE-T2T CDSS tool architecture. cSLEDAI-2k, Clinical Systemic Lupus Erythematosus Disease Activity Index 2000; PGA: Physician Global Assessment; SLEDAI-2K, SystemicLupus Erythematosus Disease Activity Index 2000.
Desktop view screenshots of the SLE-T2T web-based application (Amsterdam UMC, all rights reserved). (A) Home page. (B) Sequence of screenshots following the evaluation process, as follow: 1. SLEDAI-2K checklist; 2. PGA visual scale from 0 to 3; 3. patient’s current medication list, divided in antimalarial, immunosuppressive therapy (including biologics) and glucocorticoids (prednisolone dosage); 4. target selection page, among remission and LLDAS; 5. output page, describing the recommendations. LLDAS: Lupus Low Disease Activity State; PGA: Physician Global Assessment; SLEDAI-2K, Systemic Lupus Erythematosus Disease Activity Index 2000.
System Usability Scores
A total of seven participants completed the SUS questionnaire for this research. The participants included rheumatologist specialised in the management of patients with SLE and clinical researchers in the field of rheumatology. The mean usability rating given by the participants was 79, on a scale of 0 (worst) to 100 (best), categorising the application as ‘good’ (in the adjectives and acceptability categories associated with SUS scores), indicating the need for minor improvements to the design. Table 2 depicts the distribution of answers for the SUS rating.
System usability average scores given by the participants and SUS final score
Qualitative analysis
The qualitative data were obtained through unstructured feedback from the participants during the evaluation calls and their comments in the SUS form and classified the eHealth tool as practical and simple to use. In terms of the system strengths, participants perceived the web-based application as an advantage, simple and intelligible as exemplified below:
I think the website is well-made and provides an easy to use SLEDAI-2K score form… for physicians who do not see patients with SLE that often, an easy to use SLEDAI-2K calculator and general treatment advices might be very useful (Clinician—Researcher in the field of SLE).
I really like that the advice is (a little) personalised (Rheumatologist).
Easy to use. It could save me some time in the daily practice…(Rheumatologist)
Some of the anticipated barriers were related to the migration of the data inputted and the advice generated to the electronic record environment:
Overall easy to use. How to implement into EPIC? Would be great if we can see changes in scores in a figure in EPIC during follow up (Rheumatologist).
Based on this, a ‘summary table’ was added and can be seen as the user input data through the whole evaluation process. Once completed, it appears at the output screen, below the recommendations. This summary table can be easily copied into electronic records to keep track of the patient evaluation.
On the other hand, the participants identified the lack of patient opinion as a barrier to know the patient’s preference when it comes to the target selection:
It would be of great value to add PROMS/patient opinion about T2T to this project, as discussed (Rheumatologist)
In spite of this, SLE-T2T is intended for healthcare professionals as users, thus, including the collection of patient-reported outcome measures (PROMs) from the patients, at this stage, was not possible. We have suggested that during the clinical evaluation, the HCPs discuss together with the patient the selection of a treatment target. Based also on this comments, the record of PROMs manually will be included during the subsequent study, to further understand the patients’ need in a T2T context.
Finally, in terms of design recommendations, most of the participants agreed that more visual aid will help to sift through the page easily.
For Physician global assessment (PGA) scale would be helpful to indicate which side of the scale is good/bad in a more visual way. Make tables for remission and LLDAS goals next to each other so it is easier to compare what the differences are (Clinician—Researcher in the field of SLE).
In this sense, the graphical design of the SLEDAI-2K table and PGA visual scale were modified and made more eye catching, which translated into an easier way to navigate the site and fill in the required data.
The participants also reported some clarifications needed in the prototype web-based application, these in terms of grammatical typos, definition and specification of cut-off levels for some measurements, which were applied to the beta version of the e-health tool.
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