Requirements and Challenges of Hospital Dashboards: A Systematic Literature Review

doi:10.21203/rs.3.rs-1450850/v1

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Requirements and Challenges of Hospital Dashboards: A Systematic Literature Review

https://doi.org/10.21203/rs.3.rs-1450850/v1

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Background: Today, the use of data in managerial and clinical processes is quite challenging due to the large volume of data, data collection from various sources, and lack of data structure. As a data management tool, dashboards play a critical role in facilitating a timely and efficient representation of data.

Objectives: This systematic review aimed to identify functional and non- functional requirements, as well as challenges of using dashboards in hospitals.

Methods: In this systematic review, four databases, including the Web of Science, PubMed, EMBASE, and Scopus, were searched to find relevant articles from 2000 until May 30, 2020. The final search was conducted on May 30, 2020. Data collection was performed using a data extraction form and reviewing the content of relevant studies on the potentials and challenges of dashboard implementation.

Results: The functional requirements for dashboards included reporting, reminders, customization, tracking, alert creation, and assessment of performance indicators. On the other hand, the non-functional requirements included the dashboard speed, security, ease of use, installation on different devices (e.g., PCs and laptops), integration with other systems, web-based design, inclusion of a data warehouse, being up-to-data, and use of data visualization elements based on the user’s needs. Moreover, the identified challenges were categorized into four groups: data sources, dashboard content, dashboard design, implementation, and integration in other systems at the hospital level.

Conclusion: Dashboards, by providing information in an appropriate manner, can lead to the proper use of information by users. In order for a dashboard to be effective in clinical and managerial processes, particular attention must be paid to its capabilities, and the challenges of its implementation need to be addressed.

Hospital

Dashboard

Capabilities

Challenge

Today, healthcare organizations, including hospitals, are struggling with different sources of information chaos, such as information overload/underload, erroneous information, information scatter, and information conflict. Information chaos not only causes dissatisfaction, fatigue, and disappointment among healthcare providers, but also exerts negative effects on patient safety [1]. On the other hand, the use of data in managerial and clinical processes is quite challenging due to the large volume of data, data collection from various sources, and lack of data structures. Consequences, such as increased errors [2], delayed care delivery [3], and reduced patient safety [4] are experienced due to poor data management and presentation.

Since hospitals provide a broad spectrum of diagnostic, curative, and administrative services in a complex and dynamic environment, there is an urgent need for continuous performance monitoring in different hospital departments for proper resource management and high-quality healthcare delivery [5]. Therefore, it is necessary for healthcare providers to obtain the necessary information using a comprehensive and organized method [6]. A dashboard is a type of data management tool that collects data from various information sources available in an organization and combines them in a concise, comprehensive, and meaningful manner as key performance indicators; there are also alarms in dashboards to represent the status of these indicators. This process allows managers to briefly evaluate the performance of their departments, identify the existing problems, and analyze their root causes to improve their performance [7, 8].

By providing accurate and timely information, dashboards are not only effective systems to meet the information needs of organizations, but are also helpful in the management of large amounts of data in these organizations [9]. Dashboards typically fall into two categories of clinical and quality dashboards. The former provides relevant data in a timely manner to help the caregivers make appropriate decisions to improve patient care [10, 11], while the latter aims to provide information to support managerial decisions, either in departments or at organizational levels [12, 13].

Both functional and non-functional requirements need to be considered when developing a dashboard. The functional requirements represent the functions and activities that a system is intended to perform or facilitate [14]. On the other hand, non-functional requirements define how a system functions and describes the quality, limitations, and constraints of the system that should be considered when implementing or expanding it [14]. Dashboards improve the accessibility, ease of use, and validity of data, leading to improved staff productivity by increasing communication between decision-makers, accelerating the decision-making process, simplifying the workflow, and reducing negligence and errors in managerial and clinical performance [15].

Evidence shows that in healthcare environments using a dashboard, the process of data collection is accelerated, the cognitive burden is reduced, the error rate is decreased, and situational awareness is improved [8, 16]. A systematic review of 11 articles showed that using a dashboard improved the access of healthcare providers to the patients' data, resulting in the improved quality of care for the patients. This study also emphasized the need for further research on design approaches to better represent the data [17].

Despite the increased application of hospital dashboards and their positive effects on patient care delivery and rapid access to information, few studies have investigated the functional and non-functional requirements and challenges of using a hospital dashboard. Therefore, the present study aimed to investigate the functional and non-functional requirements and challenges of dashboards in hospitals.

Data sources and search strategy

The present study was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [18]. The Web of Science, PubMed, EMBASE, and Scopus databases were searched to identify relevant studies. In the search strategy, combinations of MeSH terms, Emtree terms, and keywords related to dashboards, Capabilities, and hospital were used (Table 1). The search was conducted on May 30, 2020. One researcher (SA) searched the literature and retrieved relevant studies independently. Any disagreements with the other author (RR) were discussed and resolved. The final stage of the search strategy was the bibliographic check of the selected articles.

Table 1

Search strategy and keywords
1#	dashboard OR whiteboard OR status board OR Electronic tracking board OR visualization OR presentation format OR display format OR performance measurement system
2#	Design OR capability OR feature OR character OR attributes OR function OR usability OR content
3#	Hospital
AND	1# AND 2# AND 3#

2.2. Inclusion and exclusion criteria

The inclusion criteria were as follows: 1) articles written in English; 2) articles that focused on quality/clinical dashboard implementation at hospitals or in hospital wards; and 3) articles that addressed functional and non-functional requirements and challenges of implementing dashboards. The exclusion criteria were non-English articles and studies investigating the implementation of clinical/quality dashboards in non-hospital settings.

2.3. Study selection, appraisal, and data extraction

The eligible articles were identified in a two stage process: 1) screening the study title and abstract; and 2) selection of articles by reviewing the full-text manuscripts. Two researchers (RR and SA) independently evaluated the retrieved articles based on the inclusion and exclusion criteria. Each reviewed article was classified as undecided, excluded, or included. The undecided articles were discussed by both reviewers, and then they performed quality assessments independently, and any discrepancies were resolved in group discussions. The Cochrane Effective Practice and Organization of Care (EPOC) guidelines were used to evaluate the quality of retrieved articles. This guideline is developed for the quality assessment of clinical trials, non-clinical trials, before-and-after trials, and case studies [25].

In the data extraction stage, the year of publication, country, and setting were documented for each article (Table 2). Next, the goals and requirements of dashboards were categorized as functional requirements, non-functional requirements, and system applications (Table 3). Besides, challenges were categorized into four groups based on similar studies: data source and data generation, dashboard content, dashboard design, and implementation and integration [19–21] (Table 4).

A total of 1,254 articles were retrieved in this study, 163 of which were removed due to duplication. Of 1,091 articles remaining, 998 were removed after reviewing their titles and abstracts (93 remaining articles). Next, the full-text manuscript of the articles was reviewed, resulting in the elimination of 43 articles. Finally, 50 articles were found eligible for this study. Besides, the reference lists of the selected articles were hand-searched, resulting in the identification of four studies. All extracted articles had an acceptable quality, and no study was removed due to low quality. Finally, a total of 54 articles were considered eligible and examined in this study. The article selection process is shown in Fig. 1.

Characteristics of eligible studies

The majority of eligible studies were performed in the USA, followed by Denmark, England, and Iran. Most of these studies (n = 43) were conducted in different departments, while 11 studies were performed at hospital levels. Among hospital wards, most studies were performed in the emergency department, followed by the radiology unit and the intensive care unit (Table 2).

Table 2

General characteristics of the included studies
Characteristics	Number of studies	Studies
Year of publication	2000	[22]
	2003	[23, 24]
	2005	[25]
	2006:	[26]
	2007	[27]
	2008	[28, 29]
	2009	[30–32]
	2010	[33–35]
	2011	[36, 37]
	2012	[38, 39]
	2013	[40–48]
	2014	[49–53]
	2015	[54, 55]
	2016	[56–58]
	2017	[59–61]
	2018	[19, 62–66]
	2019	[67–72]
	2020	[72–74]
Country	USA	[22–30, 32–34, 37, 39, 41, 42 45, 46, 51, 53–55, 59, 59, 62–65, 71, 72, 74]
	Denmark	[35, 36, 43, 56, 67, 70]
	Iran	[44, 57, 68]
	United kingdom	[40, 47, 49, 69]
	Canada	[31,48
	Norway	[50]
	Scotland	[52]
	Israel:	[58]
	Australia	[61, 73]
	South Korea	[60, 66]
	Netherlands	[19]
	Singapore	[38]
Setting	Hospital	[19, 31, 40, 42, 48, 50, 54, 60, 63, 69, 72]
	Breast cancer department	[73]
	General ward	[52]
	Department of neurosurgery	[51]
	Emergency department	[23, 25, 28, 34–36, 39, 41, 43, 53, 56, 58, 59, 61, 62, 66, 67, 70, 71]
	Maternity units	[47, 49]
	Radiology department	[22, 24, 26, 29, 30, 33, 44, 46, 57, 64, 65]
	ICU:6	[32, 38, 45, 55, 68, 74]
Pharmacy department	[27, 37]

Hospital dashboard requirements

The requirements were categorized into functional and non-functional (Table 3).

Table 3

Goals and requirements for a hospital dashboard
Dashboard’s application and requirements		Studies
System applications	Quality of care assessment	[24, 26,, 28–31, 39, 48–51, 53–55, 57, 59–62, 65, 66, 74]
	Resource management	[25, 28, 52, 71]
	Activities monitoring	[22, 24–31, 36, 38, 45–66, 68, 70–72, 74]
	Analysis and forecasting	[30–32, 48, 65, 68]
Functional requirements	Customization	[26–44, 50–52, 57–60, 62–66, 68–74]
	Alert creation	[23, 26, 28–30, 33, 35–38, 40–45, 47–49, 53, 54, 56–60, 63–66, 68–70, 72, 73]
	Tracking	[28, 33, 43–49, 53, 54, 56, 57]
	Performance indicators measurement	[27, 31, 36, 39, 44, 45, 48, 57, 59–62, 69, 71, 72]
	Reporting	[22–49, 53–55, 57–72, 74]
	Reminder messages	[26, 29]
Non-functional requirements	Use data visualization elements to display data based on user needs	[19, 24, 27–45, 57,58, 61–64, 66–74 ]
	Ability to install on a variety of devices such as PC and Laptop	[ 25, 49, 58, 69]
	Speed	[28, 36, 43, 69]
	Integration with other systems	[26, 28, 29, 30, 32, 36, 50, 53, 57, 64, 60, 68, 69, 74]
	Security	[19, 44, 30, 44, 57, 60, 66]
	Ease of use	[27, 28, 36, 42, 60, 63, 68, 71]
	Web based	[22, 24–26, 29, 30, 37, 44, 49–53, 55, 59, 63, 73]
	Having a data warehouse	[27, 28, 30, 44, 60]

Challenges with dashboards and solutions

The identified challenges were categorized into four groups: data sources and data generation, dashboard content, dashboard design, and implementation and integration. The proposed strategies to eliminate these challenges are presented in Table 4.

Table 4

Challenges with dashboards and Solutions
	Main challenges	Solutions
Data Sources and data generation	Combining multiple computerized systems Different data formats Data quality Fragmented source systems Redundancy and repeated entry of the same data Manual data entry ] 26, 27, 29, 30, 40, 47, 54, 56, 69, 71, 72[	Entering the correct data into the dashboard [44] Create data warehouse [27, 30, 44, 57] Use of automatic data collection methods [47] Use of web service architecture and middleware [26, 29, 44]
Dashboard content	Different needs and desires of users The information displayed by the dashboard does not match the needs of users Non-compliance of key performance indicators with the goals of the organization Problems with measuring too many performance indicators Patient privacy ]19, 31, 36, 41, 46–48, 50, 57, 59[	Stakeholder participation [19, 31, 36, 44, 54, 63] Identify performance indicators appropriate to the goals of the organization and avoid selecting too many indicators [44]
Table 3(count)
Dashboard design	Users’ differing executive duties Cognitive abilities and analytical skills Problem with understanding and interpreting the type of information displayed through visualization tools Amount of information presented on dashboard Provide timely data [19, 26, 33, 34, 36, 40, 41, 54, 69, 70]	Use of customization Use of colour-coding system [19, 31, 32, 48, 49, 57, 63] Use of visualization [44] Accurate understanding of the capabilities of existing systems [34]
Implementation and integrating	lack of compatibility with workflows Context sensitivity Lack of integration with other hospital systems Service disruption System security Accessing the dashboard Increased workload [19, 26, 28, 33–37, 40, 44, 50, 56, 67, 69, 70, 72]	Use of data exchange standards [19, 26, 30, 33, 44, 51, 57]. Pay attention to dashboard security due to integration with other systems [19, 44, 57, 60] User training [36] Gradual implementation of the system [36]

This systematic review aimed to identify the functional and non-functional requirements and challenges of using dashboards in hospital settings. Based on the findings, reporting, customization, reminders, assessment of performance indicators, alert creation, and tracking were identified as the functional requirements. Similar studies have reported monitoring, collection, analysis, performance measurement, and reporting as the main functional requirements [75, 76]. In a study by Buttigieg et al., monitoring, analysis, alerts, and color coding were described as the main functional requirements [7]. Besides, Ghazi Saeedi et al. found alarms, drill down, and timely presentation as the central features of dashboards [20]. Other proposed features of dashboards include forecasting, scenario analysis, and bookmarking [12, 78].

Previous studies found speed, security, ease of use, and integration in other systems as the main non-functional features of dashboards [79]. The findings of the present study also indicated the importance of the mentioned features as non-functional requirements. Moreover, attention to the user-friendliness and user interface (UI) of the software, tailored to the needs of users, increases the successful implementation and continuous use of the system [80]; the findings of these studies are in line with the present research.

In the current study, the identified challenges were categorized into four groups: data sources and data generation, dashboard content, dashboard design, and implementation and integration. In a study by Rasmussen et al., four types of challenges, including presentation format, integration, interface design, and development and implementation, were described [21]. Since the presentation format is related to the UI design [81], in the present study, it was classified as dashboard design.

Similarly, Ghazi Saeedi et al. reported four types of implementation challenges, including the development of performance indicators, data sources and data generation, integration of dashboards in source systems, and information presentation problems [20]. In the present study, the development of performance indicators was classified as dashboard content. Regarding the challenges of data sources, due to the dispersion of systems and storing data in different formats in these systems, the creation of a data warehouse for data storage and web service architecture is suggested. Besides, development of a data warehouse is one of the methods to prevent duplications in a dashboard [21, 82, 83].

According to previous studies, data availability is also a major prerequisite for dashboard development [12, 84]. Besides, a service-oriented architecture is necessary for encapsulating data from different systems in a middleware layer for data integration in dashboards, and understanding various data hosting structures, different methods of data proliferation and transfer, and the best query language are necessary for this data structure [85].

In the present study, in relation to the type of information displayed by the dashboard and non-compliance with user needs, user participation and focus on selecting indicators appropriate to the goals of the organization is proposed. Evidence suggests the necessity of engaging users in dashboard development and adaptation processes to reduce resistance to the implementation of these systems [21].

Generally, it is important to select the type and number of indicators in a dashboard [86, 87], and every organization needs to select appropriate indicators depending on its goals [88]. Evidence shows that at least 15 to 25 indicators are essential in a dashboard [89].

In the present study, to have a compatible system with the users’ cognitive abilities and skills and to provide information in a timely manner s, the capability of customization (to display information tailored to the user’s needs), color-coding systems, and visualization tools has been suggested. Overall, the findings of the current study were consistent with previous studies. According to previous studies, features, such as drill-down, filter, and alerts, are needed in dashboards for customizing the data depending on the user’s needs [12, 17, 90]. Overall, customization is an essential feature for organizing the dashboard content according to the users’ needs and promoting its application by the users [89, 91]. Besides, a color-coding system can be useful for a better understanding and interpretation of displayed information [12].

Additionally, the present study highlighted the importance of integrating data exchange standards, determining data access levels for dashboards, gradual adaptation of dashboards, and user training as potential solutions to facilitate dashboard adaptation and address its incompatibility with other systems. Since different hospital systems are integrated and linked to dashboards, particular attention should be paid to data security. In addition, data exchange standards are necessary for communication between systems and their integration in hospitals (92). Theoretically, depending on the importance and quality of information in dashboards, the level of data accessibility can be controlled at different security/privacy levels [93]. It is also recommended to control the level of access based on the user's role and incorporate features, such as read-only or write/edit access [93, 94]. Moreover, the use of “single sign-on” technology is recommended for user login [95]. The present findings also indicated the significant contribution of gradual dashboard implementation and inclusion of features based on the users’ needs for achieving success and meeting the users’ needs [96].

It is important to address some limitations of this study. First, all retrieved articles were written in English. Second, data were extracted by one researcher (SA) and evaluated by two researchers (SA and RR), which probably resulted in the unintended removal of some eligible studies. Finally, the inclusion and exclusion criteria of this study focused on the implemented hospital-level dashboards, while those used for data management related to a particular disease were excluded.

As a data management tool, dashboards play a significant role in managing significant amounts of data in healthcare settings, including hospitals. According to the findings, functional requirements for a hospital dashboard were as follows: reporting, customization, reminders, assessment of performance indicators, alert creation, and tracking. Also, non-functional indicators included speed, security, ease of use, installation on different devices (e.g., PCs and laptops), integration in other systems, web-based design, inclusion of a data warehouse, being up-to-data, and use of data visualization elements based on the users' needs; these features contribute to the adaptation and success of dashboards. Considering the challenges of dashboard implementation in hospital settings, particular attention needs to be paid to data sources, dashboard content, UI design, and dashboard implementation and integration in other hospital systems.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable as the paper does not contain any individual person’s data.

Availability of data and materials

All data used in the publication of this work were obtained from published studies. The abstracts for these studies are available in the web of science, pubmed, embase, and scopus database.

Competing interests

The authors declare that they have no conflict of interest.

Funding/Support

Not applicable.

Authors’ Contribution
Concept and design: SA and RR; Literature search and quality check: SA and RR; Data analysis and interpretation: SA and RR; Manuscript drafting: SA; Editing and critical review: RR; both authors read and approved the final manuscript.

Acknowledgements

Not applicable.

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Requirements and Challenges of Hospital Dashboards: A Systematic Literature Review

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Abstract

Figures

Introduction

Methods

Data sources and search strategy

2.2. Inclusion and exclusion criteria

2.3. Study selection, appraisal, and data extraction

Findings

Characteristics of eligible studies

Hospital dashboard requirements

Challenges with dashboards and solutions

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1