We performed a prospective mixed methods study within 3 distinct phases of data collection (Table 1) and analysis. Participants were physicians from 2 large academic institutions: the Children’s Hospital of Philadelphia (CHOP) and the University of Rochester Medical Center (URMC). Annual trainee cohort sizes are over 500 and over 900, respectively [29,30]. These programs cultivate cultures of planned learning by embedding residents in mentored research projects and data-driven quality improvement teams where they critically reflect on performance metrics, identify specific gaps in outcomes, and develop targeted interventions that close those gaps through iterative, supervised cycles of implementation and assessment [31,32]. We conducted the study over a 2-year period, from June 2021 to September 2023.

For coding paradigms in all qualitative research, a 4-member coding team reached cooperative consensus. All had full access to the complete qualitative datasets. Each team member independently reviewed first-cycle coding of all raw data prior to weekly consensus sessions. In these meetings, the team interrogated discrepant interpretations and pursued dialogical intersubjectivity until group consensus was reached. We also refined codebooks in this way, revising, collapsing, or generating new codes, categories, and themes as warranted.

The first phase of an HCD process, work domain assessment, identifies individuals’ roles and details the overall context or work system in which a prototype tool would be used [33,34]. We conducted semistructured interviews with a purposive sample of stakeholders involved in trainee-planned learning. Collecting data from all roles involved is essential to characterize a sociotechnical system of clinical work accurately [35]. Role-specific interview guides covered 2 subjects: trainee sensemaking and decision-making in practice-area learning; mentor or program perspectives on entrustment ladders and how practice-area gaps are identified, discussed, and closed (Multimedia Appendix 1).

We coded the corpus of qualitative data (Table 2). Notably, we borrowed constructs in the Systems Engineering Initiative for Patient Safety to create early cycle topic codes [35,36]. From early cycle coding analysis, we created process maps visually representing dynamics of planned learning.

To begin formative testing, we required an initial prototype. We initiated further coding processes (Table 1), first inferring key user questions, such as “Will I see important diagnoses if I choose elective X?” These questions formed the basis of an important design artifact in HCD, the feature prioritization matrix (FPM; Figure 1).

We produced an initial prototype of a planned learning support tool using the FPM from a collaborative unmoderated design session informed by reviewing recently completed process maps. We reached consensus on data visualizations that would allow trainees to identify or close gaps in experience (Figure 2). This action is the core of planned learning, and we formed the first report with visualizations supporting it.

We then iterated on the design in interview walkthroughs with users. With each walkthrough, newly elicited features and corresponding visualizations were added to the FPM and report. Using an impact metric from the completed FPM (Multimedia Appendix 2) and descriptions of required data for each visualization, we determined which features the current system architecture could feasibly support. We then produced a final version of our planned learning tool, the “minimum viable (MV) midpoint report,” including only the most impactful, feasible visualizations (Multimedia Appendix 3).

Whereas formative usability testing is meant to expose design flaws and drive prototype iteration forward, summative usability testing is meant to validate a prototype that designers theorize is ready for deployment. We developed a summative usability test to assess usability and use of the “MV midpoint report” and measure performance on MAL planning-related tasks using the report (Multimedia Appendix 4). Participants completed 5 tasks (Figure 3). For each task, participants used the report to answer one of the following key user questions:

In this way, the final cycle of analysis and design in the HCD process would be complete (Multimedia Appendix 5).

For each task, we developed a scenario with realistic clinical data and a single complementary test question to which an MV report feature offered an answer. The purpose of each scenario-question pair was to assess usability and use. Four of the 5 scenarios were paired with a multiple-choice question. A fifth scenario was paired with a free-text response. Participants in this usability test were thus assessed with these 5 scenario-question pairs.

Participants were given the MV report in advance of the test for optional review. Participants were told to suspend disbelief and answer questions in the test as though the report were their own, aggregating their own practice area data and encountering the described scenarios during residency.

Participants completed a pretest questionnaire that asked postgraduate year of the participant, whether and how they kept records of their practice areas, and if so, perceived usability (PU) and perceived ease of use (PEOU) of that system. This quantified the usability of participants’ baseline approaches to tracking practice-area exposure (if any) for comparison against our tool. PU and PEOU questions were adapted from the development of another successfully implemented CDS tool (Table 3) [44].

We report these descriptive statistics for the groups of measures that assessed PU and PEOU immediately after scenarios, PU and PEOU summarily at the very end of the test, and for the group assessing the realism of the scenarios. Scenario-question pairs were scored for correctness and used to calculate the task completion rate (TCR) by dividing correct answers by total answered questions. We also report average task completion time as the amount of time spent from a scenario-question load page to the submission of a correct response.

This study protocol was reviewed by the institutional review boards (IRBs) of both CHOP (IRB 18-014866) and URMC (study 00006717) and determined to meet exemption criteria. We obtained a waiver of written informed consent from both IRBs. Participant data were deidentified and stored by random identifier to protect subject privacy. The participants were not compensated for their participation.

We interviewed 8 participants (Table 4). We deployed initial descriptive and provisional coding efforts. Starting from the top of the codebook, 4 People, Environment, Tools, and Tasks scan categories were decomposed into 34 topics which yet further broke down into 57 subtopics. Multimedia Appendix 5 links key quotations from the interviews for each of the People, Environment, Tools, and Tasks categories and traces their impact forward through all study phases.

Through our process or causation coding and process map analysis, we produced 7 maps describing processes across 3 roles: trainees (Figure 4), trainee mentors or program directors, and program administrators. The documents mapped 52 decisions or forks in the processes with 128 other steps, actions, or changes in the mental model (Multimedia Appendix 6).

We first established that mentors and program directors had fewer existing assessment workflows than trainees. While their leadership and expertise amplified potential impact they could achieve with better practice data, trainees had a far greater volume of opportunity to identify gaps and close them for themselves. Residents, in particular, had the highest number of planning and assessment opportunities. While other populations could still be influential secondary users of an EDS, residents emerged as optimal primary users of a decision support tool targeting planned learning.

Reviewing the process maps, we determined that clinic and rotations were high-inertia settings with high mental stimulation for our trainee users. The heavy demands on cognitive resources meant that planning in these situations would be secondary to a primary use case that also emerged from the data.

Alternatively, trainee-mentor meetings, conducted much less frequently, stood out as a key target experience. By the time trainees meet with their mentors, they have usually formed some idea of a learning state gap but lack the expert system knowledge required for planning its closure. The MAL model holds that planned learning occurs by cycling through states of planning, learning, assessing, and adjusting. These meetings offered a calm moment when trainees and mentors cooperatively identify gaps, make plans to close them, or assess those efforts. This is the critical work of the planning and assessing phases. This trainee-mentor meeting environment had other benefits. It also allowed for contingency plans and provided a structure for replanning in future meetings, both of which are optimal planning practices from the standpoint of human factors engineering and cognitive science (Figure 5).

Based on the results of our workflow assessment, we designed an initial report containing a single page of placeholder visualizations. Seven participants (6 program directors and 1 resident) completed the formative usability test, iterating from this initial version. Iterations to the midpoint report were made following each test, adding new and altering extant features. The seventh version of the report following the final formative interview contained 51 distinct visualizations of trainee past and potential future data, spanning nine pages (Figure 6). The complete FPM contained a corresponding 51 records (Multimedia Appendix 6). Following feature reduction, the MV midpoint report contained 5 visualizations over 3 pages, assuming one elective under consideration where an additional page would be added for each elective.

Eight resident physician participants in total completed the summative test; 4 each from CHOP and the URMC (n=4, 50%). The TCR across all 5 scenario-question pairs, defined by the selection of the correct answer to a scenario’s accompanying multiple-choice question, was 78%. Mean task completion time was 2 minutes and 39 seconds (SD 2 minutes and 30 seconds). Results broken out by each of the 5 scenario-question pair tasks (Table 5) show that completion-time variance was primarily driven by task 1 which showed a much longer mean time and wider range than the other tasks. This may have included orientation time with the structure of the test as well as the MV midpoint report. Tasks 3 and 4 most negatively impacted overall TCR. This may be attributed to more salient, earlier visualizations in the report being used in favor of more setting-specific data breakdowns required for these questions. The summative usability test data and capture plan did not allow for more thorough error type analysis.

The pretest questionnaire provided baseline findings. Seven of the 8 participants reported no systematic method for tracking their practice-area exposure. Only 1 participant reported using an EHR-based workaround (described in a free text survey field as “saving patient reports on Epic”), and rated this approach 5/9 for both PU and PEOU (scores 6‐9 considered positive).

PU and PEOU scores for the MV midpoint report were high (Table 6). The median scores for scenario-assessed PU and scenario-assessed PEOU were 8 (IQR 5-9) and 8 (IQR 6-9), respectively. Scenario realism received a median score of 8 (IQR 6-9). Distinct from the scenario-assessed PU and PEOU that followed each of the 5 scenarios, a single summary questionnaire assessed the same measures at the end of the test. The median summaries for PU and PEOU were 8 (IQR 8-9) and 7.5 (IQR 7-8.25), respectively.

In this study, we describe the HCD process used to develop and assess a user interface to an EDS system that we find likely to be adopted. Like many designs for complex sociotechnical systems, an initial phase to better understand the implementation context led to substantial changes in our design goal. We shifted from a tool that trainees might use regularly to a tool for longer-term planning in the context of trainee-mentor meetings and potential choice of future elective rotations. We subsequently followed a typical iterative design and formative testing process. Upon achieving a stable “MV” design, we conducted our summative testing. Given that our goal in summative testing is to predict future adoption of the tool by trainees, we supplement typical usability measures of task completion, efficiency, and perceived satisfaction with an assessment of perceived usefulness and intent to use, consistent with the technology acceptance model (TAM) [45].

Systems have been judged above average in their usability when TAM-based questionnaires reach 80% [46]. High TAM usability scores signify intent to use a tool, and intent is the highest predictor of adoption [45]. This predictive factor is strengthened by high TCR [47]. Unfortunately, it is known in usability research that meta-analysis has not set completion rate benchmarks [48]. Deference, however, to TCR of similar tools at testing is standard practice in their place [49]. In comparable analytics software from education or clinical data analysis in sensemaking, reflective contexts (as opposed to CDS for real-time use preceding immediate, nonreversible patient action), we find similar TCR [46,50,51]. Matching this standard, we may draw the conclusion that our scores suggest the likely adoption of the tool.

The Accreditation Council for Graduate Medical Education requires trainees to experience a range of diagnoses during graduate medical training [1]. Using an EDS system, we can facilitate appropriate diversity of patient experiences and better quantify outcomes in GME using informatics tools [52-54]. Previous efforts to attribute trainee patient experiences have been limited in scope and dissemination. Several automated systems rely solely on EHR data to link clinical practice directly with education to personalized, timely outcomes [10,16,53]. However, these systems do not attribute patient experiences across clinical contexts or institutions. Dashboards to facilitate the feedback of clinical data to both GME and to continuous professional development have had mixed effectiveness, citing development without proper learning system stakeholder involvement and the absence of facilitated precepting to understand their learning gaps [55,56]. Our tool follows established HCD methods to include those users in interaction conception and make precepting intuitive.

With the usability and PU demonstrated in the summative test, we will implement the MV report to assist trainees with a number of tasks: visualizations of their top diagnosis types seen; their gaps in exposure compared to their peers and historical comparisons; their exposure to complex care patients; and most importantly, diagnosis makeup of electives or clinics that trainees could choose to further their exposure in weak areas of knowledge. The report will be delivered to trainees and their mentors before scheduled meetings biannually and will be discussed by the pair. Among other decisions that the report may inform, it will simplify the critical choice of electives or clinics that trainees can choose to better close their training gaps.

The formative testing sample over-represented mentors or program leaders relative to trainees; however, the final MV report was evaluated with resident end users in summative usability testing.

The study is limited by the sample size at 2 institutions, which may not represent the breadth of GME experience. Because of this, projected adoption based on high scores on PU and PEOU assessments may not be generalizable, and ongoing measurement will be necessary during implementation.

The level of realism achieved in the simulations required participants to suspend disbelief. All participants had experience and context to create clear mental settings from experience in the medical education system, though the fidelity achieved by descriptive text in immersing participants in that reality is low. In addition, the level of realism was tempered by technological limitations. We could not use actual trainee data from each specific participant or generalized trainee data from each site. Reports were populated by data that did not map to participants’ clinical experience, instead showing a generalized portrait of an “average” resident validated by clinical experts, requiring further suspension of disbelief.

Future work will improve validity deficiencies by using trainee-specific data in usability testing in a multicenter study with a greater sample drawn from more institutions, additionally including error type analysis of failed tasks. Exploration should also attempt to draw insights from beyond the EHR to triangulate them from multiple datasets including those from sources like training management systems, health care workforce management platforms, and other self-reported data. Similar efforts are already underway to support professional development [57,58]. A follow-up longitudinal study should examine click-stream engagement metrics, long-term post-deployment satisfaction via psychometrics, and downstream effects, such as changes in elective selection patterns, increased exposure in previously underrepresented diagnoses, and improvements in competency-based assessments.

We iteratively developed and performed usability testing on a 5-visualization report displaying trainees’ aggregate practice area data from the EHR. Our results indicate a high likelihood of the report’s adoption as an effective tool in graduate medical education, aligning with the MAL planning phase tasks and allowing them to be completed in a timely manner. We assessed use and usability with instruments and results that predict significant future adoption. Evolving research will examine downstream effects on entrustment following implementation. This study provides a successful user interface for functions executed from an educational decision support system and offers a foundation for further research of clinical and educational applications of this system.