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Physicians’ Perceptions of a Situation Awareness–Oriented Visualization Technology for Viscoelastic Blood Coagulation Management (Visual Clot): Mixed Methods Study

Physicians’ Perceptions of a Situation Awareness–Oriented Visualization Technology for... Background: Viscoelastic tests enable a time-efficient analysis of coagulation properties. An important limitation of viscoelastic tests is the complicated presentation of their results in the form of abstract graphs with a multitude of numbers. We developed Visual Clot to simplify the interpretation of presented clotting information. This visualization technology applies user-centered design principles to create an animated model of a blood clot during the hemostatic cascade. In a previous simulation study, we found Visual Clot to double diagnostic accuracy, reduce time to decision making and perceived workload, and improve care providers’ confidence. Objective: This study aimed to investigate the opinions of physicians on Visual Clot technology. It further aimed to assess its strengths, limitations, and clinical applicability as a support tool for coagulation management. Methods: This was a researcher-initiated, international, double-center, mixed qualitative-quantitative study that included the anesthesiologists and intensive care physicians who participated in the previous Visual Clot study. After the participants solved six coagulation scenarios using Visual Clot, we questioned them about the perceived pros and cons of this new tool. Employing qualitative research methods, we identified recurring answer patterns, and derived major topics and subthemes through inductive coding. Based on them, we defined six statements. The study participants later rated their agreement to these statements on five-point Likert scales in an online survey, which represented the quantitative part of this study. Results: A total of 60 physicians participated in the primary Visual Clot study. Among these, 36 gave an interview and 42 completed the online survey. In total, eight different major topics were derived from the interview field note responses. The three most common topics were “positive design features” (29/36, 81%), “facilitates decision making” (17/36, 47%), and “quantification not made” (17/36, 47%). In the online survey, 93% (39/42) agreed to the statement that Visual Clot is intuitive and easy to learn. Moreover, 90% (38/42) of the participants agreed that they would like the standard result and Visual Clot displayed on the screen side by side. Furthermore, 86% (36/42) indicated that Visual Clot allows them to deal with complex coagulation situations more quickly. Conclusions: A group of anesthesia and intensive care physicians from two university hospitals in central Europe considered Visual Clot technology to be intuitive, easy to learn, and useful for decision making in situations of active bleeding. From the responses of these possible future users, Visual Clot appears to constitute an efficient and well-accepted way to streamline the decision-making process in viscoelastic test–based coagulation management. http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al (JMIR Serious Games 2020;8(4):e19036) doi: 10.2196/19036 KEYWORDS blood coagulation; hemostasis; blood coagulation test; point of care; rotational thromboelastometry; Visual Clot; decision making; survey and questionnaires; situation awareness; user-centered design; qualitative research; visualization; avatar protocol and issued a declaration of no objection (Business Introduction Management System for Ethics Committees Number 2018-00933). We obtained written informed consent from each For optimal perioperative bleeding management, a quick and participant for the use of their data. reliable assessment of the patient’s blood coagulation function is of utmost importance [1-3]. As laboratory coagulation testing Study Design can take more than an hour [4] to produce results, viscoelastic We conducted this study at the University Hospital Frankfurt point-of-care devices, such as rotational thromboelastometry (UKF) in Germany and the University Hospital Zurich (USZ) (ROTEM, Instrumentation Laboratory/Werfen) and in Switzerland. We included anesthesiologists and intensive thromboelastography (Haemonetics) play an important role in care physicians from these two hospitals. Both study centers guiding hemostatic interventions in a time-efficient manner [5]. routinely use ROTEM-guided hemostatic resuscitation. Previous studies showed that the utilization of viscoelastic testing can improve the patient outcome in those with bleeding This study is a researcher-initiated, international, dual-center, trauma [3,6-9]. Hence, the European guidelines on trauma mixed qualitative-quantitative study about the opinions of management recommend viscoelastic testing to enable anesthesia and intensive care physicians regarding Visual Clot goal-directed bleeding management [10]. Furthermore, technology. The methods employed included interviewing viscoelastic point-of-care coagulation testing reduces the physicians after their first contact with Visual Clot technology transfusion of allogeneic blood products in trauma [2,10]. and jointly generating field notes based on their answers. Previous studies also showed the benefits of its use in cardiac Further, we created statements derived from these field note [1,11,12], transplant [13], neuro [14], and pediatric surgery [5]. responses and asked the same group of physicians to rate the statements in an online survey. However, the abstract presentation of viscoelastic test results complicates its handling in clinical routine. This in turn shows Previous Visual Clot Study and Participant Interviews the demand for a tool that facilitates the interpretation of We held interviews for the qualitative part of this study at the viscoelastic readings. To serve this apparent need, Visual Clot end of the data collection sessions of the previously published technology [15] was developed. Visual Clot is an alternative Visual Clot study. In the mentioned study, the participating situation awareness–oriented visualization technology created physicians evaluated 12 coagulation scenarios in randomized by adhering to the principles of user-centered design [16]. order. They solved each scenario twice, once only observing Instead of abstract shapes and a multitude of numbers, as in the Visual Clot and once only using the conventional viscoelastic conventional presentation of the ROTEM results, Visual Clot test results. Before the testing took place, the participants technology displays a three-dimensional animated model of a received brief individual training and subsequently solved six blood clot that corresponds to the real phenomena one would scenarios using Visual Clot to become familiar with its features. see when looking at the blood clot through an electron We based the individual training on a Microsoft PowerPoint microscope. In an international dual-center study [15], Visual presentation (Microsoft Corporation). This aimed to explain all Clot technology enabled the participating physicians to make visualizations of Visual Clot and enabled the participants to ask twice as many correct diagnoses quicker and with improved questions in case of uncertainties. Multimedia Appendix 1 shows diagnostic confidence and reduced perceived cognitive workload the training video for the current version of Visual Clot. Figure compared with standard viscoelastic test results. 1 explains and illustrates some visualizations of Visual Clot technology. This study aimed to explore and capture the opinions of the 60 anesthesiologists and intensive care specialists from the previous In an undisturbed environment, we asked the physicians about Visual Clot study [15] on this new visualization technology. the advantages and disadvantages of Visual Clot. There was no The results will help define the strengths and limitations of this further guidance by the investigators, who all had previous visual decision aid. Further, this study examined the applicability experience with qualitative research. While the physicians were of Visual Clot as an additional tool for coagulation management encouraged to freely verbalize their thoughts, the data collector from the viewpoint of its potential future users. simultaneously took field notes in a Microsoft Word (Microsoft Corporation) document. After the interview session, the field Methods notes were presented to the participants. They were asked whether they agreed with them and were encouraged to Approval and Consent determine final adjustments and changes. The leading ethics committee (the Cantonal Ethics Committee of the Canton of Zurich in Switzerland) reviewed the study http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al Figure 1. Graphics illustrating Visual Clot technology. A: The different coagulation components that Visual Clot represents as either present or absent (when dashed). B: A healthy Visual Clot with all coagulation elements present in sufficient quantity. C: A bleeding Visual Clot with heparin effect. D: A bleeding Visual Clot indicating the absence of plasmatic factors. DWT is a senior anesthesiologist with previous experience in Qualitative Analysis qualitative and patient safety research. Adhering to the criteria We used a template approach in the qualitative analysis [17]. for reporting qualitative research [20], TRR and DWT developed This involves grouping topics using a coding template. The a coding template as a rating system, using both word count topics are often predefined in advance. During further data and inductive coding based on recurring topics in the field note analysis, new topics are added or existing ones are revised [17]. responses. We modified the initial coding template by successive First, we translated the original answers from German to English reading, coding of the data, and discussions with other authors. using DeepL [18]. All translated field notes are available in After multiple data coding events, we agreed upon a final Multimedia Appendix 2. After translation, we used Microsoft template. The two study authors mentioned above then Word to identify the most common words and created a tag independently rated all field notes using an illustrated final cloud (Figure 2) as its quantitative graphic illustration using coding template, which has been provided in Figure 3. Interrater Wordle [19]. We ignored common English words (the, and, to, reliability was calculated to investigate the consistency of the etc) and unified word groups with the same word root. The two implementation of the rating system. In cases of disagreement physicians and study authors TRR and DWT were both involved between these two examiners, a final code for the respective in the qualitative analysis of the field notes. TRR is a resident field note response was jointly determined. anesthesiologist who did not partake in the interviewing process. http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al Figure 2. A tag cloud as a quantitative graphic illustration of the most common words in the interview field notes. This word cloud was created using Wordle.net. Common English words (the, and, to, etc) are not displayed. Frequently occurring terms have larger font sizes. Figure 3. The coding template displaying the major topics and associated subthemes. We generated this through deductive coding via word count and inductive free coding of recurring topics in the interview field notes. A total of 36 participants were interviewed. confirm specific observations made in a qualitative analysis Quantitative Analysis [21]. To further examine the qualitative research part of this Literature provides several arguments why qualitative data could study and Visual Clot applicability, we performed a quantitative be combined with a quantitative analysis. One of the reasons assessment of the derived statements using a web-based online for this is that quantitative data can help to generalize and survey. We defined six partially generalized statements and http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al asked the participants to rate them on five-point Likert scales the agreement or disagreement. This procedure additionally with responses ranging from “strongly disagree” to “strongly increases the relevance of the statements made. agree.” Out of all six statements, four directly refer to the Data Sharing Statement previously identified major topics. We specifically added two The translated interview field notes are available in Multimedia additional statements to the questioning that we considered Appendix 2. We report all other data in this manuscript. necessary. These two aimed to obtain a deeper understanding of Visual Clot technology applicability. Using SurveyMonkey Results (SVMK Inc), we created the open online survey and tested its usability before sending the study link via email to all physicians Study and Participant Characteristics who participated in the previous Visual Clot study and still worked at the respective institutions. We informed the This study included the same participants as in the previous participants that the survey takes about 1 minute to fill out. Visual Clot study [15]. A total of 60 anesthesia and intensive Participation was voluntary, no incentives were offered, and no care physicians participated. Half of them were working at the personal identifying information was collected. The participants USZ and the other half at the UKF. After collecting data from were able to review and change their answers before completion. the first 24 participants of the Visual Clot study, we decided to A single reminder to complete the survey was sent after 2 weeks. conduct systematic interviews as we found that the participants Multimedia Appendix 3 displays the translated wording of the provided very informative feedback on the technology. We survey invitation announcement as well as the reminder mail. interviewed all of the participants at the UKF and six We completed the data collection 1 week after the reminder participants at the USZ (total of 36 out of 60 [60%]). Regarding period expired. the online survey, we present the results according to the checklist for reporting results of internet e-surveys [22]. We Statistical Analysis sent out the study link as an invitation to all physicians who We provide the quantitative analysis data of the online survey still worked at the respective institutions. We checked the IP as median and interquartile range for all statements. Using the address displayed on the SurveyMonkey website to identify Wilcoxon signed-rank test, we evaluated the difference between potential duplicate entries from the same user. Since the the median for each of the statements and the neutral answer. computers in the hospitals are shared and the workspace usually We considered P<.05 to indicate statistical significance. The only changes daily, we considered a difference of at least 24 qualitative part of this study aimed to identify the pros and cons hours as appropriate for entries from the same IP address. Of using the new visualization technology. With the evaluated all invitations sent out for the online survey, the participation statements of the online survey, we aimed to further quantify rate was 86% (42/49). Table 1 further outlines the study and participant characteristics in detail. Table 1. Study and participant characteristics. Characteristics Value Study characteristics Total number of participants, n 60 Total number of interviewed participants (field notes) (N=60), n (%) 36 (60) Online survey participation rate (N=49), n (%) 42 (86) Online survey completion rate (N=42), n (%) 42 (100) Participant characteristics Female sex (N=60), n (%) 23 (38) Senior physicians (N=60), n (%) 35 (58) Resident physicians (N=60), n (%) 25 (42) Anesthesia experience in years, mean (IQR) 8 (4-11) 40 (10-53) Number of annually interpreted ROTEM readings per physician, mean (IQR) ROTEM: rotational thromboelastometry. interpretation/interpret/interpreting (13/36 participants, 36%), Part I: Qualitative Analysis of Interview Answers presentation (12/36 participants, 33%), good (11/36 participants, The analysis of word count showed the following 12 most 31%), clear (11/36 participants, 31%), frequently occurring words or word groups in the participants’ simple/simplification/simplicity (10/36 participants, 28%), field note responses: visual/visualization/visually (24/36 understand/understood/understandable (10/36 participants, participants, 67%), easy/easier/easily (18/36 participants, 50%), 28%), quick/quicker/quickly (6/36 participants, 17%), R O TEM (18/36 participants, 50%), cut-off/cut-off values (6/36 participants, 17%), and http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al hyperfibrinolysis (6/36 participants, 17%). Figure 2 provides independently. A total of 131 codes were assessed. Interrater the tag cloud created from the word count of the field note reliability was 71%, with a Cohen kappa of 0.665. After the responses. first run, TRR and DWT discussed all differences and agreed on a coding in the case of disagreement. The second run showed Through inductive free coding, we identified eight major topics an interrater agreement of 100% between the coding of TRR with associated subthemes. Figure 3 displays the generated and DWT. Table 2 outlines all major topics with participant coding template, which was used as a coding system. The two counts, percentages, and examples. study authors TRR and DWT rated all 36 field note responses Table 2. The major topics with participant count, percentages, and examples (N=36) Major topic Examples Positive design features (29 participants, 81%) Participant #15: Intuitive kind of presentation. Participant #7: Clear presentation, no unnecessary information to distract. Participant #1: Obviously, something like this was missing. Facilitates decision making (17 participants, 47%) Participant #19: Creates clarity in emergency situations. Participant #30: Perceived diagnostic confidence is higher. Saves cognitive resources (15 participants, 42%) Participant #9: Don’t have to think as much as with conventional ROTEM. Participant #16: Couldn’t imagine, that it could be presented in such a simple way! Easy to learn (14 participants, 39%) Participant #05: Even without extensive previous education. Participant #33: Easy. Self-explaining. Participant #13: Fast learning. Accelerates treatment (13 participants, 36%) Participant #19: You can see immediately where the problem is. Participant #24: Quickly realize what the problem is. Participant #26: Faster with the Visual Clot. Participant #30: You get the answer much faster. User groups (9 participants, 25%) Participant #25: Can be used safely by all educational levels. Quantification not made (17 participants, 47%) Participant #14: No quantitative data or information. Negative design features (17 participants, 47%) Participant #22: Missing fibrin is not detected and understood easily. Participant #23: Heparin effect is a little tricky to interpret. Saves Cognitive Resources Themes Of the 36 participants, 15 (42%) indicated that using Visual Positive Design Features Clot, the user saves cognitive resources compared with standard ROTEM readings. The two subthemes “less brainwork needed” Of the 36 participants, 29 (81%) made comments that fit the and “easy understanding of complex topic” are derived from major topic positive design features. After additional inductive this major topic. Some participants mentioned that they did not free coding, this topic was further divided into the three have to think as much using Visual Clot. Another participant subthemes “intuitive design,” “clear visualization,” and reasoned that using Visual Clot, he did not need to memorize “innovative idea.” Some participants perceived the visualization the cut-off values. as intuitive, while others pointed out its clear visualization of standard ROTEM results. Participant #7 stated that there was Easy to Learn no unnecessary information to distract. Others indicated Visual Of the 36 participants, 14 (39%) remarked that Visual Clot Clot as innovative, as they perceived this idea to be missing. technology is easy to learn. Participant #25 felt that after a short Facilitates Decision Making instruction, one is already able to use Visual Clot correctly. Of the 36 participants, 17 (47%) noticed during the interview Accelerating Treatment process how Visual Clot technology facilitated their decision Of the 36 participants, 13 (36%) found Visual Clot to accelerate making on fulfilling the given task. After free inductive coding, treatment. This major topic was subdivided into the aspects this major topic was broken down into the subtheme “safety in “quick recognition of situation” and “time saving.” Some decision making” as some of these participants mentioned this participants mentioned that using Visual clot, most of the aspect. Participant #2 stated how using Visual Clot made him information is visible at a single look. Further, it helps them to less afraid of getting involved with the ROTEM analysis. interpret the coagulation status faster. Additionally, participant #19 pointed out that the simplicity of Visual Clot technology created clarity in emergency situations. http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al The first statement showed that half of the participants User Groups considered the use of ROTEM readings in the management of Of the 36 participants, 9 (25%) made comments that fit the coagulopathies difficult, whereas the other half did not. major topic user groups. All of them shared the opinion that Visual Clot would especially help an inexperienced user in the The six statements with the evaluation of the online survey interpretation of ROTEM readings. Participant #25 noted that rating results are as follows: the visualization technology can be safely used at all educational (1) “I find the interpretation of the conventional presentation levels. of the ROTEM and the management of coagulopathies difficult.” Quantification Not Made This statement does not differ statistically significantly from neutral (P=.54). Of the 36 participants, 17 (47%) had concerns about the missing quantitative data using Visual Clot. Participant #16 suggested (2) “I find Visual Clot intuitive and I could learn the to show the visualization technology and the conventional interpretation easily.” Of the 42 participants, 39 (93%) agreed ROTEM results next to each other to overcome this issue. Some or strongly agreed with this statement (P<.001). mentioned how Visual Clot does not show the extent of the (3) “Visual Clot allows me to quickly grasp complex clotting coagulation disorder. Participant #2 was concerned about situations.” Of the 42 participants, 36 (86%) agreed or strongly whether this technology was reliable. agreed with this statement (P<.001). Negative Design Features (4) “I think Visual Clot is helpful in the decision-making process Of the 36 participants, 17 (47%) made comments that fit the for a targeted therapy.” Of the 42 participants, 34 (81%) agreed major topic “negative design features.” Problems in or strongly agreed with this statement (P<.001). differentiating between hyperfibrinolysis and a low fibrinogen state were mentioned by several participants. Moreover, the (5) “I required more cognitive resources for the interpretation heparin effect was difficult to interpret. Participant #1 found of Visual Clot than for the interpretation of the conventional the heparin visualization confusing. ROTEM.” Of the 42 participants, 1 (2%) agreed with this statement (P<.001). Part II: Quantitative Analysis of Statements Rated in (6) “I would find it helpful to have the visualization of Visual the Online Survey Clot and the conventional ROTEM on the screen next to each We illustrate the ratings of the six statements from the online other.” Of the 42 participants, 38 (90%) agreed or strongly survey in Figure 4. The sample medians of statements two to agreed with this statement (P<.001). six all differed statistically significantly from neutral (P<.001). Figure 4. Online survey results presented as donut parts of whole charts with the number of participants who chose a particular category (N=42). We present the results as medians and interquartile ranges and provide P values. ROTEM: rotational thromboelastometry. http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al level of such presentation. In order to increase the cognitive Discussion receptiveness of information, we intentionally animated Visual Clot in a playful way [31,32]. This enhances user accessibility Principal Findings to the otherwise dry data-driven conventional result printouts. This mixed-methods study analyzed the opinions of physicians Prior to taking part in the study, none of the participants had regarding Visual Clot, a new situation-awareness oriented ever seen Visual Clot technology. However, the number of visualization technology for viscoelastic coagulation correct decisions, time to decision, diagnostic confidence, and management. The main findings were that the participants workload improved greatly with the new tool compared with perceived Visual Clot as intuitive, easy to learn, and helpful in conventional ROTEM result presentation [15]. This study the decision-making process for ROTEM-guided coagulation reveals high agreement between user perceptions and the management. Further, they found that Visual Clot gave them a function of the technology described in the previous Visual Clot good overview of the clotting situation. The main criticism study. This correspondence between expected and provided concerned its missing quantification. The participants preferred function is another essential feature for the success of new this visualization on a screen next to the conventional ROTEM technologies. If this agreement does not occur, it can lead to readings. In an environment where health care providers are false expectations, frustration, and ultimately reduced user confronted with increasingly polymorbid patients and acceptance. Most of the answers given concerning its design complicated diagnostic tools [23,24], more efficient assistive features were positive (29/36, 81%). Nevertheless, we identified technologies leading to safer transmission of critical information some design features that led to confusion. For example, one will be of lasting importance for human performance and patient visualization aimed to show that a test for heparin was carried safety. out but turned out negative. This visualization intended to show Our study showed a high level of physician acceptance and an excluded heparin effect, but it confused some participants. satisfaction with the new tool. Eighty-one percent (34/42) of For this reason, we modified the current version of Visual Clot. the participants regarded the animated blood clot as useful in Now, it only displays heparin as present or not present. This is the decision-making process for coagulation management. Only more in line with its situation awareness–oriented intention to one participant (N=42, 2%) agreed to the statement “I required show only essential information about coagulation disorders. more cognitive resources for the interpretation of Visual Clot Moreover, based on the participants’ feedback, we further than for the interpretation of conventional ROTEM.” The refined the visualization of hyperfibrinolysis and fibrin participant responses corresponded to the reactions to the deficiency. We follow both quantitative (ie, participants’ similarly well-accepted Visual Patient technology [25]. In that performance with a particular visualization) and qualitative assessment, only 11% (4/38) of the questioned subjects study results in such design modifications. Qualitative feedback considered that technology not helpful in patient monitoring is often valuable to understand why a particular visualization after their first contact with it [26]. Visual Patient is a situation is not working. This provides clues on how we can adapt it. awareness–oriented visualization for patient vital signs with Eighty-six percent (36/42) of the participants agreed to the comparable effect size in information transfer improvement as statement that Visual Clot allowed them to grasp complex that of Visual Clot [27-30]. Ninety-three percent (39/42) of the coagulation situations more quickly. Ninety percent (38/42) of participants considered Visual Clot intuitive to interpret and the participants considered it helpful to have Visual Clot and easy to learn. In the Visual Patient study [26], 82% (31/38) of the conventional ROTEM on the screen next to each other. We the respondents attributed the same characteristics to Visual regard such an integrated display mode as optimal, as Visual Patient. The higher complexity of Visual Patient with far more Clot technology converts the continuous numerical values of visualizations may have caused the 10% difference in this aspect standard test outputs into categorical visualizations. For between the two technologies. Intuition enables humans to apply example, there can be too few, a healthy amount of, or too many a new tool utilizing mainly unconscious processing and platelets. This simplification has the advantage that information previously learned experiential knowledge [31]. Cognitive ease is understood quickly and easily, bearing in mind that this when learning a new technology is crucial for user acceptance reduces the resolution of given data. Indeed, 47% (17/36) of [32]. Indeed, previous medical visualization technologies failed the interview participants made comments regarding the missing because they were too difficult to understand [33,34]. We drafted quantification of the disorders using Visual Clot. Hence, an Visual Clot and its visualizations based on principles of logic, ideal implementation must combine the benefits of Visual Clot, human-computer interaction, and results of prior work in which are fast and easy situation recognition, with the high medical interface and user-centered design [16,34]. According precision advantage of the conventional method. A hospital to the theory by Wittgenstein [35], a coherent image or model may configure the visualization limits of Visual Clot according has a meaningful commonality with the reality it is intended to to the values of the local coagulation algorithm. This could help reflect. To achieve this, we designed Visual Clot as a model of enforce the local standard procedure. a blood clot. This philosophy is in line with results from the study by Wachter et al, which show that an anatomically correct The main goal of Visual Clot technology is still to simplify interface is particularly intuitive [33]. A previous National complex viscoelastic test results in real time to facilitate the Aeronautics and Space Administration publication outlines the care providers’ overview of the clotting situation. This study various hierarchical levels of information representation [36]. showed how potential future users perceived this technology It highlights the “order of wholeness” achieved by integrating after using it for the first time. Opinions, such as good and clear the required information into a single display as the highest visualizations and ability to obtain a good overview of the http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al clotting situation in a time-efficient manner, fully support our randomly, but selected them according to their availability in main intention. Acutely bleeding patients benefit from faster the daily clinical routine. However, the high participation rate and more accurate diagnosis and treatment. This study made us in the quantitative analysis reduces potential selection bias. aware about the desire of our fellow physicians for such Finally, we conducted this study in university hospitals with technology, from which we can draw fundamental motivation high standards of care in central Europe. Users’ opinions may to further develop its concept. be different in other parts of the world. More research is needed in this respect as well. Limitations Conclusions This study has several limitations. The opinions obtained cannot be extrapolated to a larger population because qualitative A group of anesthesiologists and intensive care physicians research does not assess statistical significance. Its only goal is regarded Visual Clot to be intuitive, easy to learn, and useful to collect and present the broadest possible range of opinions for the decision-making process in acute clotting disorders. The and views. Second, we questioned the participants after their limitation of the visualization technology resulting from the first contact with the new technology in a controlled instruction translation of continuous measurement values into categorical setting. Its use in the everyday clinical routine could alter the values was the most frequently mentioned potential disadvantage care providers’ opinions. However, we consider it unlikely that of the technology. A split-screen implementation may be used Visual Clot would not be perceived as positively in clinical to combine the advantages of the visualization technology and routine as it was in this study setting, as we observed widespread conventional technology. In this study, Visual Clot appeared to approval by anesthesiologists and intensive care physicians, be a well-accepted decision support tool for ROTEM-based who are the potential future users. Nevertheless, further research coagulation management. Further research is needed to is needed to identify the strengths and weaknesses of Visual investigate its potential in clinical practice and medical Clot technology in a clinical setting. Another limitation concerns education. the selection of participants. We did not include participants Acknowledgments The authors are thankful to the study participants for their time and effort. The Institute of Anesthesiology of the University Hospital Zurich, Zurich, Switzerland, funded this study, and DWT received a career development grant from the University of Zurich. Authors' Contributions TRR, SS, JR, DRS, CBN, and DWT helped to design the study. TRR, JR, CBN, PM, CBN, and DWT helped to collect the data. TRR, SS, CBN, and DWT helped to analyze the data. TRR, SS, JR, MG, PM, KZ, DRS, CBN, and DWT helped to write the manuscript and approved the final version. TRR and SS contributed equally. Conflicts of Interest The University of Zurich owns the intellectual property rights to the technology described in this manuscript and registered “Visual Clot” as a trademark. The University of Zurich and Instrumentation Laboratory Company/Werfen Corporation signed a letter of intent regarding a proposed joint development and licensing agreement to develop a product based on the concept of Visual Clot. As designated inventors, DRS, CBN, and DWT may receive royalties in the event of commercialization. PM received research grants from Pfizer and Dr. F. Köhler Chemie GmbH for an investigator-initiated trial; honoraria for scientific lectures from Abbott GmbH and Co KG, Aesculap Academy, B. Braun Melsungen, Biotest AG, Vifor Pharma, Ferring, CSL Behring, German Red Cross/Institute of Transfusion Medicine, HCCM Consulting GmbH, Heinen and Löwenstein, Pharmacosmos, and Siemens Healthcare; and prizes from Aktionsbündnis Patientensicherheit, European Society of Anaesthesiology, Lohfert-Stiftung AG, Masimo–Patient Safety Foundation, and MSD-Gesundheitspreis. KZ received honoraria or travel support for consulting or lecturing from the following companies: Abbott GmbH and Co KG, AesculapAkademie GmbH, AQAI GmbH, AstellasPharma GmbH, AstraZeneca GmbH, Aventis Pharma GmbH, B. Braun Melsungen AG, Baxter Deutschland GmbH, Biosyn GmbH, Biotest AG, Bristol-Myers Squibb GmbH, CSL Behring GmbH, Dr. F. Köhler Chemie GmbH, Dräger Medical GmbH, Essex Pharma GmbH, Fresenius Kabi GmbH, Fresenius Medical Care, Gambro Hospal GmbH, Gilead, GlaxoSmithKline GmbH, Grünenthal GmbH, Hamilton Medical AG, HCCM Consulting GmbH, Heinen+Löwenstein GmbH, Janssen-Cilag GmbH, med Update GmbH, Medivance EU BV, MSD Sharp and Dohme GmbH, Novartis Pharma GmbH, Novo Nordisk Pharma GmbH, P. J. Dahlhausen and Co GmbH, Pfizer Pharma GmbH, Pulsion Medical Systems SE, Siemens Healthcare, Teflex Medical GmbH, Teva GmbH, TopMedMedizintechnik GmbH, Verathon Medical, and ViforPharma GmbH. KZ’s department receives unrestricted educational grants from B. Braun Melsungen AG, Fresenius Kabi GmbH, CSL Behring GmbH, and Vifor Pharma GmbH. No other external funding or competing interests are declared. DRS’s academic department receives grant support from Swiss National Science Foundation, Swiss Society of Anesthesiology and Reanimation, Swiss Foundation for Anesthesia Research, and Vifor SA. DS is co-chair of the ABC-Trauma Faculty, sponsored by unrestricted educational grants from Novo Nordisk Health Care AG, CSL Behring GmbH, LFB Biomedicaments, and Octapharma AG. DRS received honoraria/travel support for consulting or lecturing from Danube University of Krems, US Department of Defense, European Society of Anesthesiology, Korean Society http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al for Patient Blood Management, Korean Society of Anesthesiologists, Baxter/Baxalta AG, Bayer AG, Bayer Pharma AG, B. Braun Melsungen AG, Boehringer Ingelheim GmbH, Bristol-Myers-Squibb, CSL Behring GmbH, Celgene International II Sarl, Daiichi Sankyo AG, Haemonetics, Instrumentation Laboratory (Werfen), LFB Biomedicaments, Merck Sharp and Dohme, Octapharma AG, Paion UK Ltd, Deutschland GmbH, Pharmacosmos A/S, Photonics Healthcare BV, Pierre Fabre Pharma, Roche Diagnostics International Ltd, Sarstedt AG & Co, Tem International GmbH, Vifor Pharma, and Vifor (International) AG. CBN and DWT received travel support for consulting and lecturing from Instrumentation Laboratory (Werfen). CBN and DWT received proof-of-concept funding from the University of Zurich to prototype the Visual Patient. The University of Zurich and Koninklijke Philips NV entered a joint development and licensing agreement to develop a product based on the Visual Patient. As inventors, CBN and DWT may receive royalty payments in the event of commercialization. The other authors do not have any conflicts of interest. Multimedia Appendix 1 Visual Clot educational video. [MP4 File (MP4 Video), 13215 KB-Multimedia Appendix 1] Multimedia Appendix 2 Translated field notes of the participant interviews. [PDF File (Adobe PDF File), 246 KB-Multimedia Appendix 2] Multimedia Appendix 3 Translated online survey announcement. [PDF File (Adobe PDF File), 79 KB-Multimedia Appendix 3] References 1. Serraino GF, Murphy GJ. Routine use of viscoelastic blood tests for diagnosis and treatment of coagulopathic bleeding in cardiac surgery: updated systematic review and meta-analysis. Br J Anaesth 2017 Jun 01;118(6):823-833 [FREE Full text] [doi: 10.1093/bja/aex100] [Medline: 28475665] 2. Schöchl H, Nienaber U, Hofer G, Voelckel W, Jambor C, Scharbert G, et al. Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Crit Care 2010;14(2):R55 [FREE Full text] [doi: 10.1186/cc8948] [Medline: 20374650] 3. Gonzalez E, Moore EE, Moore HB, Chapman MP, Chin TL, Ghasabyan A, et al. Goal-directed Hemostatic Resuscitation of Trauma-induced Coagulopathy: A Pragmatic Randomized Clinical Trial Comparing a Viscoelastic Assay to Conventional Coagulation Assays. Ann Surg 2016 Jun;263(6):1051-1059 [FREE Full text] [doi: 10.1097/SLA.0000000000001608] [Medline: 26720428] 4. Davenport R, Manson J, De'Ath H, Platton S, Coates A, Allard S, et al. Functional definition and characterization of acute traumatic coagulopathy. Crit Care Med 2011 Dec;39(12):2652-2658 [FREE Full text] [doi: 10.1097/CCM.0b013e3182281af5] [Medline: 21765358] 5. Wikkelsø A, Wetterslev J, Møller AM, Afshari A. Thromboelastography (TEG) or thromboelastometry (ROTEM) to monitor haemostatic treatment versus usual care in adults or children with bleeding. Cochrane Database Syst Rev 2016 Aug 22(8):CD007871 [FREE Full text] [doi: 10.1002/14651858.CD007871.pub3] [Medline: 27552162] 6. Schöchl H, Nienaber U, Maegele M, Hochleitner G, Primavesi F, Steitz B, et al. Transfusion in trauma: thromboelastometry-guided coagulation factor concentrate-based therapy versus standard fresh frozen plasma-based therapy. Crit Care 2011;15(2):R83 [FREE Full text] [doi: 10.1186/cc10078] [Medline: 21375741] 7. Nystrup KB, Windeløv NA, Thomsen AB, Johansson PI. Reduced clot strength upon admission, evaluated by thrombelastography (TEG), in trauma patients is independently associated with increased 30-day mortality. Scand J Trauma Resusc Emerg Med 2011 Sep 28;19:52 [FREE Full text] [doi: 10.1186/1757-7241-19-52] [Medline: 21955460] 8. Stein P, Kaserer A, Spahn GH, Spahn DR. Point-of-Care Coagulation Monitoring in Trauma Patients. Semin Thromb Hemost 2017 Jun;43(4):367-374. [doi: 10.1055/s-0037-1598062] [Medline: 28297730] 9. Hunt H, Stanworth S, Curry N, Woolley T, Cooper C, Ukoumunne O, et al. Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) for trauma induced coagulopathy in adult trauma patients with bleeding. Cochrane Database Syst Rev 2015 Feb 16(2):CD010438 [FREE Full text] [doi: 10.1002/14651858.CD010438.pub2] [Medline: 25686465] 10. Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019 Mar 27;23(1):98 [FREE Full text] [doi: 10.1186/s13054-019-2347-3] [Medline: 30917843] 11. Görlinger K, Dirkmann D, Hanke AA, Kamler M, Kottenberg E, Thielmann M, et al. First-line therapy with coagulation factor concentrates combined with point-of-care coagulation testing is associated with decreased allogeneic blood transfusion http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al in cardiovascular surgery: a retrospective, single-center cohort study. Anesthesiology 2011 Dec;115(6):1179-1191 [FREE Full text] [doi: 10.1097/ALN.0b013e31823497dd] [Medline: 21970887] 12. Weber CF, Görlinger K, Meininger D, Herrmann E, Bingold T, Moritz A, et al. Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology 2012 Sep;117(3):531-547 [FREE Full text] [doi: 10.1097/ALN.0b013e318264c644] [Medline: 22914710] 13. Mallett SV. Clinical Utility of Viscoelastic Tests of Coagulation (TEG/ROTEM) in Patients with Liver Disease and during Liver Transplantation. Semin Thromb Hemost 2015 Jul;41(5):527-537. [doi: 10.1055/s-0035-1550434] [Medline: 26049072] 14. Kvint S, Schuster J, Kumar MA. Neurosurgical applications of viscoelastic hemostatic assays. Neurosurg Focus 2017 Nov;43(5):E9. [doi: 10.3171/2017.8.FOCUS17447] [Medline: 29088950] 15. Rössler J, Meybohm P, Spahn DR, Zacharowski K, Braun J, Nöthiger CB, et al. Improving decision making through presentation of viscoelastic tests as a 3D animated blood clot: the Visual Clot. Anaesthesia 2020 Aug 06;75(8):1059-1069. [doi: 10.1111/anae.14985] [Medline: 32030729] 16. Endsley M. Designing for Situation Awareness: An Approach to User-Centered Design, Second Edition. Boca Raton: CRC Press, Inc; 2011. 17. Symon G, Cassell C. Qualitative Organizational Research: Core Methods and Current Challenges. Thousand Oaks, CA: SAGE Publications; 2012. 18. DeepL. URL: https://www.deepl.com [accessed 2020-11-17] 19. Wordle. URL: http://www.wordle.net/ [accessed 2020-11-17] 20. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007 Dec;19(6):349-357 [FREE Full text] [doi: 10.1093/intqhc/mzm042] [Medline: 17872937] 21. Miles M, Huberman A. Qualitative Data Analysis: A Methods Sourcebook. Thousand Oaks, CA: SAGE Publications; 1994. 22. Eysenbach G. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res 2004 Sep 29;6(3):e34 [FREE Full text] [doi: 10.2196/jmir.6.3.e34] [Medline: 15471760] 23. Gulland A. Shortage of health workers is set to double, says WHO. BMJ 2013 Nov 12;347:f6804. [doi: 10.1136/bmj.f6804] [Medline: 24222676] 24. Zimmerman JE, Kramer AA, Knaus WA. Changes in hospital mortality for United States intensive care unit admissions from 1988 to 2012. Crit Care 2013 Apr 27;17(2):R81 [FREE Full text] [doi: 10.1186/cc12695] [Medline: 23622086] 25. Tscholl DW, Rössler J, Said S, Kaserer A, Spahn DR, Nöthiger CB. Situation Awareness-Oriented Patient Monitoring with Visual Patient Technology: A Qualitative Review of the Primary Research. Sensors (Basel) 2020 Apr 09;20(7):2112 [FREE Full text] [doi: 10.3390/s20072112] [Medline: 32283625] 26. Tscholl DW, Weiss M, Handschin L, Spahn DR, Nöthiger CB. User perceptions of avatar-based patient monitoring: a mixed qualitative and quantitative study. BMC Anesthesiol 2018 Dec 11;18(1):188 [FREE Full text] [doi: 10.1186/s12871-018-0650-1] [Medline: 30537934] 27. Tscholl DW, Handschin L, Neubauer P, Weiss M, Seifert B, Spahn DR, et al. Using an animated patient avatar to improve perception of vital sign information by anaesthesia professionals. Br J Anaesth 2018 Sep;121(3):662-671 [FREE Full text] [doi: 10.1016/j.bja.2018.04.024] [Medline: 30115265] 28. Garot O, Rössler J, Pfarr J, Ganter MT, Spahn DR, Nöthiger CB, et al. Avatar-based versus conventional vital sign display in a central monitor for monitoring multiple patients: a multicenter computer-based laboratory study. BMC Med Inform Decis Mak 2020 Feb 10;20(1):26 [FREE Full text] [doi: 10.1186/s12911-020-1032-4] [Medline: 32041584] 29. Pfarr J, Ganter MT, Spahn DR, Noethiger CB, Tscholl DW. Avatar-Based Patient Monitoring With Peripheral Vision: A Multicenter Comparative Eye-Tracking Study. J Med Internet Res 2019 Jul 17;21(7):e13041 [FREE Full text] [doi: 10.2196/13041] [Medline: 31317870] 30. Tscholl DW, Rössler J, Handschin L, Seifert B, Spahn DR, Nöthiger CB. The Mechanisms Responsible for Improved Information Transfer in Avatar-Based Patient Monitoring: Multicenter Comparative Eye-Tracking Study. J Med Internet Res 2020 Mar 16;22(3):e15070 [FREE Full text] [doi: 10.2196/15070] [Medline: 32175913] 31. Blackler A, Popovic V, Mahar D. Investigating users' intuitive interaction with complex artefacts. Appl Ergon 2010 Jan;41(1):72-92. [doi: 10.1016/j.apergo.2009.04.010] [Medline: 19586618] 32. Agarwal R, Karahanna E. Time Flies When You're Having Fun: Cognitive Absorption and Beliefs about Information Technology Usage. MIS Quarterly 2000 Dec;24(4):665. [doi: 10.2307/3250951] 33. Wachter SB, Agutter J, Syroid N, Drews F, Weinger MB, Westenskow D. The employment of an iterative design process to develop a pulmonary graphical display. J Am Med Inform Assoc 2003;10(4):363-372 [FREE Full text] [doi: 10.1197/jamia.M1207] [Medline: 12668693] 34. Drews FA, Westenskow DR. The right picture is worth a thousand numbers: data displays in anesthesia. Hum Factors 2006;48(1):59-71. [doi: 10.1518/001872006776412270] [Medline: 16696257] 35. Wittgenstein L. Tractatus logico-philosophicus. London: COSIMO CLASSICS; 2007. 36. Degani A, Jorgensen C, Iverson D, Shafto M, Olson L. On Organization of Information: Approach and Early Work. Washington, DC: National Aeronautics and Space Administration; 2009. http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al Abbreviations ROTEM: rotational thromboelastometry UKF: University Hospital Frankfurt USZ: University Hospital Zurich Edited by N Zary; submitted 01.04.20; peer-reviewed by M Endsley, C Hoving; comments to author 23.04.20; revised version received 16.06.20; accepted 10.11.20; published 04.12.20 Please cite as: Roche TR, Said S, Rössler J, Gozdzik M, Meybohm P, Zacharowski K, Spahn DR, Nöthiger CB, Tscholl DW Physicians’ Perceptions of a Situation Awareness–Oriented Visualization Technology for Viscoelastic Blood Coagulation Management (Visual Clot): Mixed Methods Study JMIR Serious Games 2020;8(4):e19036 URL: http://games.jmir.org/2020/4/e19036/ doi: 10.2196/19036 PMID: 33172834 ©Tadzio Raoul Roche, Sadiq Said, Julian Rössler, Malgorzata Gozdzik, Patrick Meybohm, Kai Zacharowski, Donat R Spahn, Christoph B Nöthiger, David W Tscholl. Originally published in JMIR Serious Games (http://games.jmir.org), 04.12.2020. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 12 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Physicians’ Perceptions of a Situation Awareness–Oriented Visualization Technology for Viscoelastic Blood Coagulation Management (Visual Clot): Mixed Methods Study

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2291-9279
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10.2196/19036
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Abstract

Background: Viscoelastic tests enable a time-efficient analysis of coagulation properties. An important limitation of viscoelastic tests is the complicated presentation of their results in the form of abstract graphs with a multitude of numbers. We developed Visual Clot to simplify the interpretation of presented clotting information. This visualization technology applies user-centered design principles to create an animated model of a blood clot during the hemostatic cascade. In a previous simulation study, we found Visual Clot to double diagnostic accuracy, reduce time to decision making and perceived workload, and improve care providers’ confidence. Objective: This study aimed to investigate the opinions of physicians on Visual Clot technology. It further aimed to assess its strengths, limitations, and clinical applicability as a support tool for coagulation management. Methods: This was a researcher-initiated, international, double-center, mixed qualitative-quantitative study that included the anesthesiologists and intensive care physicians who participated in the previous Visual Clot study. After the participants solved six coagulation scenarios using Visual Clot, we questioned them about the perceived pros and cons of this new tool. Employing qualitative research methods, we identified recurring answer patterns, and derived major topics and subthemes through inductive coding. Based on them, we defined six statements. The study participants later rated their agreement to these statements on five-point Likert scales in an online survey, which represented the quantitative part of this study. Results: A total of 60 physicians participated in the primary Visual Clot study. Among these, 36 gave an interview and 42 completed the online survey. In total, eight different major topics were derived from the interview field note responses. The three most common topics were “positive design features” (29/36, 81%), “facilitates decision making” (17/36, 47%), and “quantification not made” (17/36, 47%). In the online survey, 93% (39/42) agreed to the statement that Visual Clot is intuitive and easy to learn. Moreover, 90% (38/42) of the participants agreed that they would like the standard result and Visual Clot displayed on the screen side by side. Furthermore, 86% (36/42) indicated that Visual Clot allows them to deal with complex coagulation situations more quickly. Conclusions: A group of anesthesia and intensive care physicians from two university hospitals in central Europe considered Visual Clot technology to be intuitive, easy to learn, and useful for decision making in situations of active bleeding. From the responses of these possible future users, Visual Clot appears to constitute an efficient and well-accepted way to streamline the decision-making process in viscoelastic test–based coagulation management. http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al (JMIR Serious Games 2020;8(4):e19036) doi: 10.2196/19036 KEYWORDS blood coagulation; hemostasis; blood coagulation test; point of care; rotational thromboelastometry; Visual Clot; decision making; survey and questionnaires; situation awareness; user-centered design; qualitative research; visualization; avatar protocol and issued a declaration of no objection (Business Introduction Management System for Ethics Committees Number 2018-00933). We obtained written informed consent from each For optimal perioperative bleeding management, a quick and participant for the use of their data. reliable assessment of the patient’s blood coagulation function is of utmost importance [1-3]. As laboratory coagulation testing Study Design can take more than an hour [4] to produce results, viscoelastic We conducted this study at the University Hospital Frankfurt point-of-care devices, such as rotational thromboelastometry (UKF) in Germany and the University Hospital Zurich (USZ) (ROTEM, Instrumentation Laboratory/Werfen) and in Switzerland. We included anesthesiologists and intensive thromboelastography (Haemonetics) play an important role in care physicians from these two hospitals. Both study centers guiding hemostatic interventions in a time-efficient manner [5]. routinely use ROTEM-guided hemostatic resuscitation. Previous studies showed that the utilization of viscoelastic testing can improve the patient outcome in those with bleeding This study is a researcher-initiated, international, dual-center, trauma [3,6-9]. Hence, the European guidelines on trauma mixed qualitative-quantitative study about the opinions of management recommend viscoelastic testing to enable anesthesia and intensive care physicians regarding Visual Clot goal-directed bleeding management [10]. Furthermore, technology. The methods employed included interviewing viscoelastic point-of-care coagulation testing reduces the physicians after their first contact with Visual Clot technology transfusion of allogeneic blood products in trauma [2,10]. and jointly generating field notes based on their answers. Previous studies also showed the benefits of its use in cardiac Further, we created statements derived from these field note [1,11,12], transplant [13], neuro [14], and pediatric surgery [5]. responses and asked the same group of physicians to rate the statements in an online survey. However, the abstract presentation of viscoelastic test results complicates its handling in clinical routine. This in turn shows Previous Visual Clot Study and Participant Interviews the demand for a tool that facilitates the interpretation of We held interviews for the qualitative part of this study at the viscoelastic readings. To serve this apparent need, Visual Clot end of the data collection sessions of the previously published technology [15] was developed. Visual Clot is an alternative Visual Clot study. In the mentioned study, the participating situation awareness–oriented visualization technology created physicians evaluated 12 coagulation scenarios in randomized by adhering to the principles of user-centered design [16]. order. They solved each scenario twice, once only observing Instead of abstract shapes and a multitude of numbers, as in the Visual Clot and once only using the conventional viscoelastic conventional presentation of the ROTEM results, Visual Clot test results. Before the testing took place, the participants technology displays a three-dimensional animated model of a received brief individual training and subsequently solved six blood clot that corresponds to the real phenomena one would scenarios using Visual Clot to become familiar with its features. see when looking at the blood clot through an electron We based the individual training on a Microsoft PowerPoint microscope. In an international dual-center study [15], Visual presentation (Microsoft Corporation). This aimed to explain all Clot technology enabled the participating physicians to make visualizations of Visual Clot and enabled the participants to ask twice as many correct diagnoses quicker and with improved questions in case of uncertainties. Multimedia Appendix 1 shows diagnostic confidence and reduced perceived cognitive workload the training video for the current version of Visual Clot. Figure compared with standard viscoelastic test results. 1 explains and illustrates some visualizations of Visual Clot technology. This study aimed to explore and capture the opinions of the 60 anesthesiologists and intensive care specialists from the previous In an undisturbed environment, we asked the physicians about Visual Clot study [15] on this new visualization technology. the advantages and disadvantages of Visual Clot. There was no The results will help define the strengths and limitations of this further guidance by the investigators, who all had previous visual decision aid. Further, this study examined the applicability experience with qualitative research. While the physicians were of Visual Clot as an additional tool for coagulation management encouraged to freely verbalize their thoughts, the data collector from the viewpoint of its potential future users. simultaneously took field notes in a Microsoft Word (Microsoft Corporation) document. After the interview session, the field Methods notes were presented to the participants. They were asked whether they agreed with them and were encouraged to Approval and Consent determine final adjustments and changes. The leading ethics committee (the Cantonal Ethics Committee of the Canton of Zurich in Switzerland) reviewed the study http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al Figure 1. Graphics illustrating Visual Clot technology. A: The different coagulation components that Visual Clot represents as either present or absent (when dashed). B: A healthy Visual Clot with all coagulation elements present in sufficient quantity. C: A bleeding Visual Clot with heparin effect. D: A bleeding Visual Clot indicating the absence of plasmatic factors. DWT is a senior anesthesiologist with previous experience in Qualitative Analysis qualitative and patient safety research. Adhering to the criteria We used a template approach in the qualitative analysis [17]. for reporting qualitative research [20], TRR and DWT developed This involves grouping topics using a coding template. The a coding template as a rating system, using both word count topics are often predefined in advance. During further data and inductive coding based on recurring topics in the field note analysis, new topics are added or existing ones are revised [17]. responses. We modified the initial coding template by successive First, we translated the original answers from German to English reading, coding of the data, and discussions with other authors. using DeepL [18]. All translated field notes are available in After multiple data coding events, we agreed upon a final Multimedia Appendix 2. After translation, we used Microsoft template. The two study authors mentioned above then Word to identify the most common words and created a tag independently rated all field notes using an illustrated final cloud (Figure 2) as its quantitative graphic illustration using coding template, which has been provided in Figure 3. Interrater Wordle [19]. We ignored common English words (the, and, to, reliability was calculated to investigate the consistency of the etc) and unified word groups with the same word root. The two implementation of the rating system. In cases of disagreement physicians and study authors TRR and DWT were both involved between these two examiners, a final code for the respective in the qualitative analysis of the field notes. TRR is a resident field note response was jointly determined. anesthesiologist who did not partake in the interviewing process. http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al Figure 2. A tag cloud as a quantitative graphic illustration of the most common words in the interview field notes. This word cloud was created using Wordle.net. Common English words (the, and, to, etc) are not displayed. Frequently occurring terms have larger font sizes. Figure 3. The coding template displaying the major topics and associated subthemes. We generated this through deductive coding via word count and inductive free coding of recurring topics in the interview field notes. A total of 36 participants were interviewed. confirm specific observations made in a qualitative analysis Quantitative Analysis [21]. To further examine the qualitative research part of this Literature provides several arguments why qualitative data could study and Visual Clot applicability, we performed a quantitative be combined with a quantitative analysis. One of the reasons assessment of the derived statements using a web-based online for this is that quantitative data can help to generalize and survey. We defined six partially generalized statements and http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al asked the participants to rate them on five-point Likert scales the agreement or disagreement. This procedure additionally with responses ranging from “strongly disagree” to “strongly increases the relevance of the statements made. agree.” Out of all six statements, four directly refer to the Data Sharing Statement previously identified major topics. We specifically added two The translated interview field notes are available in Multimedia additional statements to the questioning that we considered Appendix 2. We report all other data in this manuscript. necessary. These two aimed to obtain a deeper understanding of Visual Clot technology applicability. Using SurveyMonkey Results (SVMK Inc), we created the open online survey and tested its usability before sending the study link via email to all physicians Study and Participant Characteristics who participated in the previous Visual Clot study and still worked at the respective institutions. We informed the This study included the same participants as in the previous participants that the survey takes about 1 minute to fill out. Visual Clot study [15]. A total of 60 anesthesia and intensive Participation was voluntary, no incentives were offered, and no care physicians participated. Half of them were working at the personal identifying information was collected. The participants USZ and the other half at the UKF. After collecting data from were able to review and change their answers before completion. the first 24 participants of the Visual Clot study, we decided to A single reminder to complete the survey was sent after 2 weeks. conduct systematic interviews as we found that the participants Multimedia Appendix 3 displays the translated wording of the provided very informative feedback on the technology. We survey invitation announcement as well as the reminder mail. interviewed all of the participants at the UKF and six We completed the data collection 1 week after the reminder participants at the USZ (total of 36 out of 60 [60%]). Regarding period expired. the online survey, we present the results according to the checklist for reporting results of internet e-surveys [22]. We Statistical Analysis sent out the study link as an invitation to all physicians who We provide the quantitative analysis data of the online survey still worked at the respective institutions. We checked the IP as median and interquartile range for all statements. Using the address displayed on the SurveyMonkey website to identify Wilcoxon signed-rank test, we evaluated the difference between potential duplicate entries from the same user. Since the the median for each of the statements and the neutral answer. computers in the hospitals are shared and the workspace usually We considered P<.05 to indicate statistical significance. The only changes daily, we considered a difference of at least 24 qualitative part of this study aimed to identify the pros and cons hours as appropriate for entries from the same IP address. Of using the new visualization technology. With the evaluated all invitations sent out for the online survey, the participation statements of the online survey, we aimed to further quantify rate was 86% (42/49). Table 1 further outlines the study and participant characteristics in detail. Table 1. Study and participant characteristics. Characteristics Value Study characteristics Total number of participants, n 60 Total number of interviewed participants (field notes) (N=60), n (%) 36 (60) Online survey participation rate (N=49), n (%) 42 (86) Online survey completion rate (N=42), n (%) 42 (100) Participant characteristics Female sex (N=60), n (%) 23 (38) Senior physicians (N=60), n (%) 35 (58) Resident physicians (N=60), n (%) 25 (42) Anesthesia experience in years, mean (IQR) 8 (4-11) 40 (10-53) Number of annually interpreted ROTEM readings per physician, mean (IQR) ROTEM: rotational thromboelastometry. interpretation/interpret/interpreting (13/36 participants, 36%), Part I: Qualitative Analysis of Interview Answers presentation (12/36 participants, 33%), good (11/36 participants, The analysis of word count showed the following 12 most 31%), clear (11/36 participants, 31%), frequently occurring words or word groups in the participants’ simple/simplification/simplicity (10/36 participants, 28%), field note responses: visual/visualization/visually (24/36 understand/understood/understandable (10/36 participants, participants, 67%), easy/easier/easily (18/36 participants, 50%), 28%), quick/quicker/quickly (6/36 participants, 17%), R O TEM (18/36 participants, 50%), cut-off/cut-off values (6/36 participants, 17%), and http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al hyperfibrinolysis (6/36 participants, 17%). Figure 2 provides independently. A total of 131 codes were assessed. Interrater the tag cloud created from the word count of the field note reliability was 71%, with a Cohen kappa of 0.665. After the responses. first run, TRR and DWT discussed all differences and agreed on a coding in the case of disagreement. The second run showed Through inductive free coding, we identified eight major topics an interrater agreement of 100% between the coding of TRR with associated subthemes. Figure 3 displays the generated and DWT. Table 2 outlines all major topics with participant coding template, which was used as a coding system. The two counts, percentages, and examples. study authors TRR and DWT rated all 36 field note responses Table 2. The major topics with participant count, percentages, and examples (N=36) Major topic Examples Positive design features (29 participants, 81%) Participant #15: Intuitive kind of presentation. Participant #7: Clear presentation, no unnecessary information to distract. Participant #1: Obviously, something like this was missing. Facilitates decision making (17 participants, 47%) Participant #19: Creates clarity in emergency situations. Participant #30: Perceived diagnostic confidence is higher. Saves cognitive resources (15 participants, 42%) Participant #9: Don’t have to think as much as with conventional ROTEM. Participant #16: Couldn’t imagine, that it could be presented in such a simple way! Easy to learn (14 participants, 39%) Participant #05: Even without extensive previous education. Participant #33: Easy. Self-explaining. Participant #13: Fast learning. Accelerates treatment (13 participants, 36%) Participant #19: You can see immediately where the problem is. Participant #24: Quickly realize what the problem is. Participant #26: Faster with the Visual Clot. Participant #30: You get the answer much faster. User groups (9 participants, 25%) Participant #25: Can be used safely by all educational levels. Quantification not made (17 participants, 47%) Participant #14: No quantitative data or information. Negative design features (17 participants, 47%) Participant #22: Missing fibrin is not detected and understood easily. Participant #23: Heparin effect is a little tricky to interpret. Saves Cognitive Resources Themes Of the 36 participants, 15 (42%) indicated that using Visual Positive Design Features Clot, the user saves cognitive resources compared with standard ROTEM readings. The two subthemes “less brainwork needed” Of the 36 participants, 29 (81%) made comments that fit the and “easy understanding of complex topic” are derived from major topic positive design features. After additional inductive this major topic. Some participants mentioned that they did not free coding, this topic was further divided into the three have to think as much using Visual Clot. Another participant subthemes “intuitive design,” “clear visualization,” and reasoned that using Visual Clot, he did not need to memorize “innovative idea.” Some participants perceived the visualization the cut-off values. as intuitive, while others pointed out its clear visualization of standard ROTEM results. Participant #7 stated that there was Easy to Learn no unnecessary information to distract. Others indicated Visual Of the 36 participants, 14 (39%) remarked that Visual Clot Clot as innovative, as they perceived this idea to be missing. technology is easy to learn. Participant #25 felt that after a short Facilitates Decision Making instruction, one is already able to use Visual Clot correctly. Of the 36 participants, 17 (47%) noticed during the interview Accelerating Treatment process how Visual Clot technology facilitated their decision Of the 36 participants, 13 (36%) found Visual Clot to accelerate making on fulfilling the given task. After free inductive coding, treatment. This major topic was subdivided into the aspects this major topic was broken down into the subtheme “safety in “quick recognition of situation” and “time saving.” Some decision making” as some of these participants mentioned this participants mentioned that using Visual clot, most of the aspect. Participant #2 stated how using Visual Clot made him information is visible at a single look. Further, it helps them to less afraid of getting involved with the ROTEM analysis. interpret the coagulation status faster. Additionally, participant #19 pointed out that the simplicity of Visual Clot technology created clarity in emergency situations. http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al The first statement showed that half of the participants User Groups considered the use of ROTEM readings in the management of Of the 36 participants, 9 (25%) made comments that fit the coagulopathies difficult, whereas the other half did not. major topic user groups. All of them shared the opinion that Visual Clot would especially help an inexperienced user in the The six statements with the evaluation of the online survey interpretation of ROTEM readings. Participant #25 noted that rating results are as follows: the visualization technology can be safely used at all educational (1) “I find the interpretation of the conventional presentation levels. of the ROTEM and the management of coagulopathies difficult.” Quantification Not Made This statement does not differ statistically significantly from neutral (P=.54). Of the 36 participants, 17 (47%) had concerns about the missing quantitative data using Visual Clot. Participant #16 suggested (2) “I find Visual Clot intuitive and I could learn the to show the visualization technology and the conventional interpretation easily.” Of the 42 participants, 39 (93%) agreed ROTEM results next to each other to overcome this issue. Some or strongly agreed with this statement (P<.001). mentioned how Visual Clot does not show the extent of the (3) “Visual Clot allows me to quickly grasp complex clotting coagulation disorder. Participant #2 was concerned about situations.” Of the 42 participants, 36 (86%) agreed or strongly whether this technology was reliable. agreed with this statement (P<.001). Negative Design Features (4) “I think Visual Clot is helpful in the decision-making process Of the 36 participants, 17 (47%) made comments that fit the for a targeted therapy.” Of the 42 participants, 34 (81%) agreed major topic “negative design features.” Problems in or strongly agreed with this statement (P<.001). differentiating between hyperfibrinolysis and a low fibrinogen state were mentioned by several participants. Moreover, the (5) “I required more cognitive resources for the interpretation heparin effect was difficult to interpret. Participant #1 found of Visual Clot than for the interpretation of the conventional the heparin visualization confusing. ROTEM.” Of the 42 participants, 1 (2%) agreed with this statement (P<.001). Part II: Quantitative Analysis of Statements Rated in (6) “I would find it helpful to have the visualization of Visual the Online Survey Clot and the conventional ROTEM on the screen next to each We illustrate the ratings of the six statements from the online other.” Of the 42 participants, 38 (90%) agreed or strongly survey in Figure 4. The sample medians of statements two to agreed with this statement (P<.001). six all differed statistically significantly from neutral (P<.001). Figure 4. Online survey results presented as donut parts of whole charts with the number of participants who chose a particular category (N=42). We present the results as medians and interquartile ranges and provide P values. ROTEM: rotational thromboelastometry. http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al level of such presentation. In order to increase the cognitive Discussion receptiveness of information, we intentionally animated Visual Clot in a playful way [31,32]. This enhances user accessibility Principal Findings to the otherwise dry data-driven conventional result printouts. This mixed-methods study analyzed the opinions of physicians Prior to taking part in the study, none of the participants had regarding Visual Clot, a new situation-awareness oriented ever seen Visual Clot technology. However, the number of visualization technology for viscoelastic coagulation correct decisions, time to decision, diagnostic confidence, and management. The main findings were that the participants workload improved greatly with the new tool compared with perceived Visual Clot as intuitive, easy to learn, and helpful in conventional ROTEM result presentation [15]. This study the decision-making process for ROTEM-guided coagulation reveals high agreement between user perceptions and the management. Further, they found that Visual Clot gave them a function of the technology described in the previous Visual Clot good overview of the clotting situation. The main criticism study. This correspondence between expected and provided concerned its missing quantification. The participants preferred function is another essential feature for the success of new this visualization on a screen next to the conventional ROTEM technologies. If this agreement does not occur, it can lead to readings. In an environment where health care providers are false expectations, frustration, and ultimately reduced user confronted with increasingly polymorbid patients and acceptance. Most of the answers given concerning its design complicated diagnostic tools [23,24], more efficient assistive features were positive (29/36, 81%). Nevertheless, we identified technologies leading to safer transmission of critical information some design features that led to confusion. For example, one will be of lasting importance for human performance and patient visualization aimed to show that a test for heparin was carried safety. out but turned out negative. This visualization intended to show Our study showed a high level of physician acceptance and an excluded heparin effect, but it confused some participants. satisfaction with the new tool. Eighty-one percent (34/42) of For this reason, we modified the current version of Visual Clot. the participants regarded the animated blood clot as useful in Now, it only displays heparin as present or not present. This is the decision-making process for coagulation management. Only more in line with its situation awareness–oriented intention to one participant (N=42, 2%) agreed to the statement “I required show only essential information about coagulation disorders. more cognitive resources for the interpretation of Visual Clot Moreover, based on the participants’ feedback, we further than for the interpretation of conventional ROTEM.” The refined the visualization of hyperfibrinolysis and fibrin participant responses corresponded to the reactions to the deficiency. We follow both quantitative (ie, participants’ similarly well-accepted Visual Patient technology [25]. In that performance with a particular visualization) and qualitative assessment, only 11% (4/38) of the questioned subjects study results in such design modifications. Qualitative feedback considered that technology not helpful in patient monitoring is often valuable to understand why a particular visualization after their first contact with it [26]. Visual Patient is a situation is not working. This provides clues on how we can adapt it. awareness–oriented visualization for patient vital signs with Eighty-six percent (36/42) of the participants agreed to the comparable effect size in information transfer improvement as statement that Visual Clot allowed them to grasp complex that of Visual Clot [27-30]. Ninety-three percent (39/42) of the coagulation situations more quickly. Ninety percent (38/42) of participants considered Visual Clot intuitive to interpret and the participants considered it helpful to have Visual Clot and easy to learn. In the Visual Patient study [26], 82% (31/38) of the conventional ROTEM on the screen next to each other. We the respondents attributed the same characteristics to Visual regard such an integrated display mode as optimal, as Visual Patient. The higher complexity of Visual Patient with far more Clot technology converts the continuous numerical values of visualizations may have caused the 10% difference in this aspect standard test outputs into categorical visualizations. For between the two technologies. Intuition enables humans to apply example, there can be too few, a healthy amount of, or too many a new tool utilizing mainly unconscious processing and platelets. This simplification has the advantage that information previously learned experiential knowledge [31]. Cognitive ease is understood quickly and easily, bearing in mind that this when learning a new technology is crucial for user acceptance reduces the resolution of given data. Indeed, 47% (17/36) of [32]. Indeed, previous medical visualization technologies failed the interview participants made comments regarding the missing because they were too difficult to understand [33,34]. We drafted quantification of the disorders using Visual Clot. Hence, an Visual Clot and its visualizations based on principles of logic, ideal implementation must combine the benefits of Visual Clot, human-computer interaction, and results of prior work in which are fast and easy situation recognition, with the high medical interface and user-centered design [16,34]. According precision advantage of the conventional method. A hospital to the theory by Wittgenstein [35], a coherent image or model may configure the visualization limits of Visual Clot according has a meaningful commonality with the reality it is intended to to the values of the local coagulation algorithm. This could help reflect. To achieve this, we designed Visual Clot as a model of enforce the local standard procedure. a blood clot. This philosophy is in line with results from the study by Wachter et al, which show that an anatomically correct The main goal of Visual Clot technology is still to simplify interface is particularly intuitive [33]. A previous National complex viscoelastic test results in real time to facilitate the Aeronautics and Space Administration publication outlines the care providers’ overview of the clotting situation. This study various hierarchical levels of information representation [36]. showed how potential future users perceived this technology It highlights the “order of wholeness” achieved by integrating after using it for the first time. Opinions, such as good and clear the required information into a single display as the highest visualizations and ability to obtain a good overview of the http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al clotting situation in a time-efficient manner, fully support our randomly, but selected them according to their availability in main intention. Acutely bleeding patients benefit from faster the daily clinical routine. However, the high participation rate and more accurate diagnosis and treatment. This study made us in the quantitative analysis reduces potential selection bias. aware about the desire of our fellow physicians for such Finally, we conducted this study in university hospitals with technology, from which we can draw fundamental motivation high standards of care in central Europe. Users’ opinions may to further develop its concept. be different in other parts of the world. More research is needed in this respect as well. Limitations Conclusions This study has several limitations. The opinions obtained cannot be extrapolated to a larger population because qualitative A group of anesthesiologists and intensive care physicians research does not assess statistical significance. Its only goal is regarded Visual Clot to be intuitive, easy to learn, and useful to collect and present the broadest possible range of opinions for the decision-making process in acute clotting disorders. The and views. Second, we questioned the participants after their limitation of the visualization technology resulting from the first contact with the new technology in a controlled instruction translation of continuous measurement values into categorical setting. Its use in the everyday clinical routine could alter the values was the most frequently mentioned potential disadvantage care providers’ opinions. However, we consider it unlikely that of the technology. A split-screen implementation may be used Visual Clot would not be perceived as positively in clinical to combine the advantages of the visualization technology and routine as it was in this study setting, as we observed widespread conventional technology. In this study, Visual Clot appeared to approval by anesthesiologists and intensive care physicians, be a well-accepted decision support tool for ROTEM-based who are the potential future users. Nevertheless, further research coagulation management. Further research is needed to is needed to identify the strengths and weaknesses of Visual investigate its potential in clinical practice and medical Clot technology in a clinical setting. Another limitation concerns education. the selection of participants. We did not include participants Acknowledgments The authors are thankful to the study participants for their time and effort. The Institute of Anesthesiology of the University Hospital Zurich, Zurich, Switzerland, funded this study, and DWT received a career development grant from the University of Zurich. Authors' Contributions TRR, SS, JR, DRS, CBN, and DWT helped to design the study. TRR, JR, CBN, PM, CBN, and DWT helped to collect the data. TRR, SS, CBN, and DWT helped to analyze the data. TRR, SS, JR, MG, PM, KZ, DRS, CBN, and DWT helped to write the manuscript and approved the final version. TRR and SS contributed equally. Conflicts of Interest The University of Zurich owns the intellectual property rights to the technology described in this manuscript and registered “Visual Clot” as a trademark. The University of Zurich and Instrumentation Laboratory Company/Werfen Corporation signed a letter of intent regarding a proposed joint development and licensing agreement to develop a product based on the concept of Visual Clot. As designated inventors, DRS, CBN, and DWT may receive royalties in the event of commercialization. PM received research grants from Pfizer and Dr. F. Köhler Chemie GmbH for an investigator-initiated trial; honoraria for scientific lectures from Abbott GmbH and Co KG, Aesculap Academy, B. Braun Melsungen, Biotest AG, Vifor Pharma, Ferring, CSL Behring, German Red Cross/Institute of Transfusion Medicine, HCCM Consulting GmbH, Heinen and Löwenstein, Pharmacosmos, and Siemens Healthcare; and prizes from Aktionsbündnis Patientensicherheit, European Society of Anaesthesiology, Lohfert-Stiftung AG, Masimo–Patient Safety Foundation, and MSD-Gesundheitspreis. KZ received honoraria or travel support for consulting or lecturing from the following companies: Abbott GmbH and Co KG, AesculapAkademie GmbH, AQAI GmbH, AstellasPharma GmbH, AstraZeneca GmbH, Aventis Pharma GmbH, B. Braun Melsungen AG, Baxter Deutschland GmbH, Biosyn GmbH, Biotest AG, Bristol-Myers Squibb GmbH, CSL Behring GmbH, Dr. F. Köhler Chemie GmbH, Dräger Medical GmbH, Essex Pharma GmbH, Fresenius Kabi GmbH, Fresenius Medical Care, Gambro Hospal GmbH, Gilead, GlaxoSmithKline GmbH, Grünenthal GmbH, Hamilton Medical AG, HCCM Consulting GmbH, Heinen+Löwenstein GmbH, Janssen-Cilag GmbH, med Update GmbH, Medivance EU BV, MSD Sharp and Dohme GmbH, Novartis Pharma GmbH, Novo Nordisk Pharma GmbH, P. J. Dahlhausen and Co GmbH, Pfizer Pharma GmbH, Pulsion Medical Systems SE, Siemens Healthcare, Teflex Medical GmbH, Teva GmbH, TopMedMedizintechnik GmbH, Verathon Medical, and ViforPharma GmbH. KZ’s department receives unrestricted educational grants from B. Braun Melsungen AG, Fresenius Kabi GmbH, CSL Behring GmbH, and Vifor Pharma GmbH. No other external funding or competing interests are declared. DRS’s academic department receives grant support from Swiss National Science Foundation, Swiss Society of Anesthesiology and Reanimation, Swiss Foundation for Anesthesia Research, and Vifor SA. DS is co-chair of the ABC-Trauma Faculty, sponsored by unrestricted educational grants from Novo Nordisk Health Care AG, CSL Behring GmbH, LFB Biomedicaments, and Octapharma AG. DRS received honoraria/travel support for consulting or lecturing from Danube University of Krems, US Department of Defense, European Society of Anesthesiology, Korean Society http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al for Patient Blood Management, Korean Society of Anesthesiologists, Baxter/Baxalta AG, Bayer AG, Bayer Pharma AG, B. Braun Melsungen AG, Boehringer Ingelheim GmbH, Bristol-Myers-Squibb, CSL Behring GmbH, Celgene International II Sarl, Daiichi Sankyo AG, Haemonetics, Instrumentation Laboratory (Werfen), LFB Biomedicaments, Merck Sharp and Dohme, Octapharma AG, Paion UK Ltd, Deutschland GmbH, Pharmacosmos A/S, Photonics Healthcare BV, Pierre Fabre Pharma, Roche Diagnostics International Ltd, Sarstedt AG & Co, Tem International GmbH, Vifor Pharma, and Vifor (International) AG. CBN and DWT received travel support for consulting and lecturing from Instrumentation Laboratory (Werfen). CBN and DWT received proof-of-concept funding from the University of Zurich to prototype the Visual Patient. The University of Zurich and Koninklijke Philips NV entered a joint development and licensing agreement to develop a product based on the Visual Patient. As inventors, CBN and DWT may receive royalty payments in the event of commercialization. The other authors do not have any conflicts of interest. Multimedia Appendix 1 Visual Clot educational video. [MP4 File (MP4 Video), 13215 KB-Multimedia Appendix 1] Multimedia Appendix 2 Translated field notes of the participant interviews. [PDF File (Adobe PDF File), 246 KB-Multimedia Appendix 2] Multimedia Appendix 3 Translated online survey announcement. [PDF File (Adobe PDF File), 79 KB-Multimedia Appendix 3] References 1. Serraino GF, Murphy GJ. Routine use of viscoelastic blood tests for diagnosis and treatment of coagulopathic bleeding in cardiac surgery: updated systematic review and meta-analysis. Br J Anaesth 2017 Jun 01;118(6):823-833 [FREE Full text] [doi: 10.1093/bja/aex100] [Medline: 28475665] 2. Schöchl H, Nienaber U, Hofer G, Voelckel W, Jambor C, Scharbert G, et al. Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Crit Care 2010;14(2):R55 [FREE Full text] [doi: 10.1186/cc8948] [Medline: 20374650] 3. Gonzalez E, Moore EE, Moore HB, Chapman MP, Chin TL, Ghasabyan A, et al. Goal-directed Hemostatic Resuscitation of Trauma-induced Coagulopathy: A Pragmatic Randomized Clinical Trial Comparing a Viscoelastic Assay to Conventional Coagulation Assays. Ann Surg 2016 Jun;263(6):1051-1059 [FREE Full text] [doi: 10.1097/SLA.0000000000001608] [Medline: 26720428] 4. Davenport R, Manson J, De'Ath H, Platton S, Coates A, Allard S, et al. Functional definition and characterization of acute traumatic coagulopathy. Crit Care Med 2011 Dec;39(12):2652-2658 [FREE Full text] [doi: 10.1097/CCM.0b013e3182281af5] [Medline: 21765358] 5. Wikkelsø A, Wetterslev J, Møller AM, Afshari A. Thromboelastography (TEG) or thromboelastometry (ROTEM) to monitor haemostatic treatment versus usual care in adults or children with bleeding. Cochrane Database Syst Rev 2016 Aug 22(8):CD007871 [FREE Full text] [doi: 10.1002/14651858.CD007871.pub3] [Medline: 27552162] 6. Schöchl H, Nienaber U, Maegele M, Hochleitner G, Primavesi F, Steitz B, et al. Transfusion in trauma: thromboelastometry-guided coagulation factor concentrate-based therapy versus standard fresh frozen plasma-based therapy. Crit Care 2011;15(2):R83 [FREE Full text] [doi: 10.1186/cc10078] [Medline: 21375741] 7. Nystrup KB, Windeløv NA, Thomsen AB, Johansson PI. Reduced clot strength upon admission, evaluated by thrombelastography (TEG), in trauma patients is independently associated with increased 30-day mortality. Scand J Trauma Resusc Emerg Med 2011 Sep 28;19:52 [FREE Full text] [doi: 10.1186/1757-7241-19-52] [Medline: 21955460] 8. Stein P, Kaserer A, Spahn GH, Spahn DR. Point-of-Care Coagulation Monitoring in Trauma Patients. Semin Thromb Hemost 2017 Jun;43(4):367-374. [doi: 10.1055/s-0037-1598062] [Medline: 28297730] 9. Hunt H, Stanworth S, Curry N, Woolley T, Cooper C, Ukoumunne O, et al. Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) for trauma induced coagulopathy in adult trauma patients with bleeding. Cochrane Database Syst Rev 2015 Feb 16(2):CD010438 [FREE Full text] [doi: 10.1002/14651858.CD010438.pub2] [Medline: 25686465] 10. Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019 Mar 27;23(1):98 [FREE Full text] [doi: 10.1186/s13054-019-2347-3] [Medline: 30917843] 11. Görlinger K, Dirkmann D, Hanke AA, Kamler M, Kottenberg E, Thielmann M, et al. First-line therapy with coagulation factor concentrates combined with point-of-care coagulation testing is associated with decreased allogeneic blood transfusion http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al in cardiovascular surgery: a retrospective, single-center cohort study. Anesthesiology 2011 Dec;115(6):1179-1191 [FREE Full text] [doi: 10.1097/ALN.0b013e31823497dd] [Medline: 21970887] 12. Weber CF, Görlinger K, Meininger D, Herrmann E, Bingold T, Moritz A, et al. Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology 2012 Sep;117(3):531-547 [FREE Full text] [doi: 10.1097/ALN.0b013e318264c644] [Medline: 22914710] 13. Mallett SV. Clinical Utility of Viscoelastic Tests of Coagulation (TEG/ROTEM) in Patients with Liver Disease and during Liver Transplantation. Semin Thromb Hemost 2015 Jul;41(5):527-537. [doi: 10.1055/s-0035-1550434] [Medline: 26049072] 14. Kvint S, Schuster J, Kumar MA. Neurosurgical applications of viscoelastic hemostatic assays. Neurosurg Focus 2017 Nov;43(5):E9. [doi: 10.3171/2017.8.FOCUS17447] [Medline: 29088950] 15. Rössler J, Meybohm P, Spahn DR, Zacharowski K, Braun J, Nöthiger CB, et al. Improving decision making through presentation of viscoelastic tests as a 3D animated blood clot: the Visual Clot. Anaesthesia 2020 Aug 06;75(8):1059-1069. [doi: 10.1111/anae.14985] [Medline: 32030729] 16. Endsley M. Designing for Situation Awareness: An Approach to User-Centered Design, Second Edition. Boca Raton: CRC Press, Inc; 2011. 17. Symon G, Cassell C. Qualitative Organizational Research: Core Methods and Current Challenges. Thousand Oaks, CA: SAGE Publications; 2012. 18. DeepL. URL: https://www.deepl.com [accessed 2020-11-17] 19. Wordle. URL: http://www.wordle.net/ [accessed 2020-11-17] 20. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007 Dec;19(6):349-357 [FREE Full text] [doi: 10.1093/intqhc/mzm042] [Medline: 17872937] 21. Miles M, Huberman A. Qualitative Data Analysis: A Methods Sourcebook. Thousand Oaks, CA: SAGE Publications; 1994. 22. Eysenbach G. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res 2004 Sep 29;6(3):e34 [FREE Full text] [doi: 10.2196/jmir.6.3.e34] [Medline: 15471760] 23. Gulland A. Shortage of health workers is set to double, says WHO. BMJ 2013 Nov 12;347:f6804. [doi: 10.1136/bmj.f6804] [Medline: 24222676] 24. Zimmerman JE, Kramer AA, Knaus WA. Changes in hospital mortality for United States intensive care unit admissions from 1988 to 2012. Crit Care 2013 Apr 27;17(2):R81 [FREE Full text] [doi: 10.1186/cc12695] [Medline: 23622086] 25. Tscholl DW, Rössler J, Said S, Kaserer A, Spahn DR, Nöthiger CB. Situation Awareness-Oriented Patient Monitoring with Visual Patient Technology: A Qualitative Review of the Primary Research. Sensors (Basel) 2020 Apr 09;20(7):2112 [FREE Full text] [doi: 10.3390/s20072112] [Medline: 32283625] 26. Tscholl DW, Weiss M, Handschin L, Spahn DR, Nöthiger CB. User perceptions of avatar-based patient monitoring: a mixed qualitative and quantitative study. BMC Anesthesiol 2018 Dec 11;18(1):188 [FREE Full text] [doi: 10.1186/s12871-018-0650-1] [Medline: 30537934] 27. Tscholl DW, Handschin L, Neubauer P, Weiss M, Seifert B, Spahn DR, et al. Using an animated patient avatar to improve perception of vital sign information by anaesthesia professionals. Br J Anaesth 2018 Sep;121(3):662-671 [FREE Full text] [doi: 10.1016/j.bja.2018.04.024] [Medline: 30115265] 28. Garot O, Rössler J, Pfarr J, Ganter MT, Spahn DR, Nöthiger CB, et al. Avatar-based versus conventional vital sign display in a central monitor for monitoring multiple patients: a multicenter computer-based laboratory study. BMC Med Inform Decis Mak 2020 Feb 10;20(1):26 [FREE Full text] [doi: 10.1186/s12911-020-1032-4] [Medline: 32041584] 29. Pfarr J, Ganter MT, Spahn DR, Noethiger CB, Tscholl DW. Avatar-Based Patient Monitoring With Peripheral Vision: A Multicenter Comparative Eye-Tracking Study. J Med Internet Res 2019 Jul 17;21(7):e13041 [FREE Full text] [doi: 10.2196/13041] [Medline: 31317870] 30. Tscholl DW, Rössler J, Handschin L, Seifert B, Spahn DR, Nöthiger CB. The Mechanisms Responsible for Improved Information Transfer in Avatar-Based Patient Monitoring: Multicenter Comparative Eye-Tracking Study. J Med Internet Res 2020 Mar 16;22(3):e15070 [FREE Full text] [doi: 10.2196/15070] [Medline: 32175913] 31. Blackler A, Popovic V, Mahar D. Investigating users' intuitive interaction with complex artefacts. Appl Ergon 2010 Jan;41(1):72-92. [doi: 10.1016/j.apergo.2009.04.010] [Medline: 19586618] 32. Agarwal R, Karahanna E. Time Flies When You're Having Fun: Cognitive Absorption and Beliefs about Information Technology Usage. MIS Quarterly 2000 Dec;24(4):665. [doi: 10.2307/3250951] 33. Wachter SB, Agutter J, Syroid N, Drews F, Weinger MB, Westenskow D. The employment of an iterative design process to develop a pulmonary graphical display. J Am Med Inform Assoc 2003;10(4):363-372 [FREE Full text] [doi: 10.1197/jamia.M1207] [Medline: 12668693] 34. Drews FA, Westenskow DR. The right picture is worth a thousand numbers: data displays in anesthesia. Hum Factors 2006;48(1):59-71. [doi: 10.1518/001872006776412270] [Medline: 16696257] 35. Wittgenstein L. Tractatus logico-philosophicus. London: COSIMO CLASSICS; 2007. 36. Degani A, Jorgensen C, Iverson D, Shafto M, Olson L. On Organization of Information: Approach and Early Work. Washington, DC: National Aeronautics and Space Administration; 2009. http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Roche et al Abbreviations ROTEM: rotational thromboelastometry UKF: University Hospital Frankfurt USZ: University Hospital Zurich Edited by N Zary; submitted 01.04.20; peer-reviewed by M Endsley, C Hoving; comments to author 23.04.20; revised version received 16.06.20; accepted 10.11.20; published 04.12.20 Please cite as: Roche TR, Said S, Rössler J, Gozdzik M, Meybohm P, Zacharowski K, Spahn DR, Nöthiger CB, Tscholl DW Physicians’ Perceptions of a Situation Awareness–Oriented Visualization Technology for Viscoelastic Blood Coagulation Management (Visual Clot): Mixed Methods Study JMIR Serious Games 2020;8(4):e19036 URL: http://games.jmir.org/2020/4/e19036/ doi: 10.2196/19036 PMID: 33172834 ©Tadzio Raoul Roche, Sadiq Said, Julian Rössler, Malgorzata Gozdzik, Patrick Meybohm, Kai Zacharowski, Donat R Spahn, Christoph B Nöthiger, David W Tscholl. Originally published in JMIR Serious Games (http://games.jmir.org), 04.12.2020. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2020/4/e19036/ JMIR Serious Games 2020 | vol. 8 | iss. 4 | e19036 | p. 12 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious GamesJMIR Publications

Published: Dec 4, 2020

Keywords: blood coagulation; hemostasis; blood coagulation test; point of care; rotational thromboelastometry; Visual Clot; decision making; survey and questionnaires; situation awareness; user-centered design; qualitative research; visualization; avatar

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