ARRA and

EMR Usability
What Providers Need to Know
Conflict of Interest Disclosure

       Jeff Belden MD
Dr. Belden is on the faculty at University of Missouri
   - Columbi...
Conflict of Interest Disclosure

 Janey Barnes PhD
     Contracted Research:
     • Allscripts,
     • Patagonia Health,
 ...
Low EMR Adoption Rates
EMR Adoption Hospitals - 2008
                                     100%


Full Basi   Basic without     None
     c      c...
EMR Adoption Doctor Offices – 2007-08

                                           100%


Full   Basic                None
...
Why?
Barriers
• Purchase price
• Uncertain ROI
• Lost productivity
• Finding an EMR that meets
  needs
• Obsolescence concerns
Usability missing




Smelcer 2009
What is ^usability?
Usability is
 Effectiveness
 Efficiency
 Satisfaction



ISO 2003
Usability means
  Learnable
  Efficient
  Memorable
  Error-free
  Satisfying

Useit.com
Current EMRs
lack good usability




Smelcer 2009
examples
Time consuming
dictation takes 33 seconds


EMR can take 10x longer
Alert Fatigue
of high-priority DDI alerts…


90% ignored
Complex steps
hard to learn


Longer, costly training
AAFP EMR Survey 2009
User satisfaction ratings
from 2,012 Family Physicians
Usability is…
10 Principles
1. Simplicity                       7. Feedback
2. Naturalness                      8. Effective use of
3. C...
Simplicity
Simplicity

For doing refills




For overview only
Naturalness
Naturalness




Old way – lots of drill-down clicking
Naturalness

Better way
we know the body
already
Consistency
Consistency




Name and identifying info consistently placed
Minimizing Cognitive Load
Minimizing Cognitive Load
Exact past dates
• This requires mental math
Minimizing Cognitive Load

Relative past dates
• Easier. No extra thinking.
Minimizing Cognitive Load

Hover to see more detail
• Have it both ways
Efficient Interactions
Efficient Interactions
Dashboard efficiency
Efficient Interactions




50 Clicks…
                 • 6 minutes
Efficient Interactions




2 Clicks…
             • 1-2 minutes
Efficient Interactions


Dashboard benefits
•   Single visual plane
•   No navigation away needed
•   No need to recall la...
Efficient Interactions




Dashboard principle
Show me

 WINWINIANM
(what I need, when I need it, and nothing more)
Forgiveness
Forgiveness

Let users discover by
exploring without fear of destroying

Let users recover gracefully
from mistakes
Forgiveness
A bad example…
Feedback
Feedback

• Don’t keep the user wondering
• Show expected delays
• Confirm changes that aren’t evident
Feedback



Imagine this scenario
• Imagine a user clicks a page element,
  and a long, slow database call
  ensues…
Acceptable
Better



         Please wait while we
             check 10,357
               records…
Best

         Time remaining… 8 seconds



       Please wait while we
           check 10,357
             records…
Effective Use of Language
Terse for doctor




Plain English for patient
Effective Information Presentation
Effective Information Presentation
Sorted alphabetically, not randomly




          Better yet, allow sort by other crite...
Preservation of Context
Preservation of Context
ARRA’s
Meaningful Use Matrix



         Where does usability fit in?
Meaningful Use (MU)


  5 Health Outcome Policy Priorities
    1. Improve quality, safety, efficiency, &
       reduce hea...
Meaningful Use (MU)


  We picked 3
    1. Improve quality, safety, efficiency, &
       reduce health disparities
    2. ...
MU > Improve Quality


  1. Improve Quality…
    1. Evidence-based CPOE
    2. Clinical decision support at the Point-of-
...
MU > Quality > EBM CPOE




          Evidence-based CPOE
             …building ruts to quality & safety


              ...
MU > Quality > EBM CPOE


  Antibiotic Selection for
  Community-Acquired Pneumonia


   Usability principles
   1. Simpli...
MU > Quality > EBM CPOE
MU > Quality > EBM CPOE > Simplicity


  Simplicity
MU > Quality > EBM CPOE > Min cognitive load


  Minimize cognitive load
MU > Quality > EBM CPOE > Efficient


  Efficient interactions
MU > Quality > CDS at POC




    Clinical Decision Support
          at the Point of Care

                            ex...
MU > Quality > CDS at POC > Problem List



  Problem Lists


   Usability principles
   1.   Simplicity
   2.   Naturalne...
MU > Quality > CDS at POC > Problem List > Simplicity




                                         Simplicity
MU > Quality > CDS at POC > Problem List > Simplicity


    The old way...
MU > Quality > CDS at POC > Problem List > Simplicity


    Better way
MU > Quality > CDS at POC > Problem List > Naturalness


Naturalness
Sort & sequence like clinicians think

 Not by diagno...
MU > Quality > CDS at POC > Problem List > Naturalness


Effective use of language

 Common ways you could display Diabete...
MU > Quality > CDS at POC > Problem List > Info Prez


Effective Info Presentation
Sorted alphabetically          Sorted f...
MU > Quality > CDS at POC > Problem List > Info Prez


Effective Info Presentation
Highlighted for cardiology   Filtered f...
MU > Quality > CDS at POC > Alerts



  Alerts


   Usability principles
   1. Simplicity
   2. Efficiency
   3. Effective...
MU > Quality > CDS at POC > Alerts > Simplicity


    Too busy visually…
MU > Quality > CDS at POC > Alerts > Simplicity


    Try to find the essence…
MU > Quality > CDS at POC > Alerts > Simplicity


    All the doctor needs to see
MU > Quality > CDS at POC > Alerts > Simplicity


    Simplicity
MU > Quality > CDS at POC > Alerts > Info Presentation


    Effective info presentation

     Show only what the physicia...
MU > Quality > CDS at POC > Alerts > Feedback


    Efficient interactions

     • Prevent repeated alerts for same
      ...
MU > Quality > CDS at POC > Lab



  Lab results


   Usability principles
   1. Effective information presentation
   2. ...
MU > Quality > CDS at POC > Lab > Info Presentation

                   Effective info presentation
 old



              ...
MU > Quality > CDS at POC > Lab > Min cognitive load


    Minimize cognitive load
MU > Quality > CDS at POC > Lab > Preserve context


    Preservation of context




    Compare to prior lab, two year gr...
MU > Quality > CDS at POC > Lab > Preserve context

 And what medication is he/she on?
 And what is the weight and BP doin...
MU > Quality > Registries




                            Registries


                              examples…
MU > Quality > CDS at POC > Problem List



  Quality Registry: Dashboard


   Usability principles
   1. Efficient intera...
MU > Quality > Registries > Quality dashboard


    Diabetes quality dashboard
MU > Quality > Registries > Quality dashboard


    Efficient interactions




     Give actionable info at Point-of-Care
MU > Engaging Patients > Access to health record




                   Engaging Patients
              Giving e-access to...
MU > Engage patients



  Clinical Summary

   Usability principles
   1. Effective use of language
   2. Efficient intera...
MU > Engage patients > Clinical summary


              Clinical Summary at Visit



    A take-home for
         the pati...
MU > Engage patients > Clinical summary
MU > Engage patients > Clinical summary


    Effective Language




                                  Plain English
MU > Engage patients > Clinical summary


    Efficient



         And
   something
      for the
       wallet
MU > Engage patients > View lab on web


  Viewing lab results on web


   Usability principles
   1. Effective use of lan...
MU > Engage patients > View lab on web


  Viewing lab results on web
MU > Engage patients > View lab on web


 Effective Language




   Change ”Reference” to ”Normal Range”
MU > Engage patients > View lab on web


                  Effective info presentation




  What would patient expect to ...
MU > Engage patients > View lab on web


 Effective Info Presentation




 Easy to misunderstand “which normal range”
MU > Engage patients > e-Copy



  Web Access or e-Copy


   Usability principles
   1. Naturalness
   2. Forgiveness
MU > Engage patients > e-Copy


  Naturalness
MU > Engage patients > e-Copy


  Forgiveness
EMR Buyer’s Guide
  Shopping for usability



      Before you buy, or implement…
MU > Before you buy



 It’s a process…
  Define what’s Important to You
  • Evaluate your alternatives
  • Select the alt...
MU > Before you buy



 What’s important to you
  Effectiveness
  •What do you want /need from your EMR?
  •How will this ...
MU > Before you buy



 What’s important to you
  Efficiency
  •What outcomes should be better
    • Faster
    • more rob...
MU > Before you buy



 What’s important to you
  Satisfaction
  •Of which users?
  •For which key tasks?
  •In which clin...
MU > Before you buy



  Evaluate Your Alternatives
  What do your friends say
     • Ask, ask, ask!
     • Go watch your ...
MU > Before you buy



  Evaluate Your Alternatives
  What do your colleagues say
     • Blogs, etc.

  What do your profe...
MU > Before you buy



  Evaluate Your Alternatives
  What do you and your team say
  • Do your own evaluation
        • C...
MU > Before you buy



  Creating Clinical Scenarios
  1.Choose ones that matter
     • frequent, important
     • Include...
MU > Before you buy



  Buyer Beware
  Try Out the Reporting Function
  • What will you want to report?
     • A1Cs in di...
MU > Before you buy



  Buyer Beware
  Don’t be “wowed” by Templates
  Don’t be impressed with installed templates
  • Tr...
MU > Before you buy



  Buyer Beware
  Training
   • Touch on initial training
      • you & staff will be overwhelmed at...
Want to learn more?
• EMR Usability Principles and
  Proposed Testing
  • http://bit.ly/UsabilityHIMSS
• Checklist - Evalu...
ARRA & Usability: What Providers Need to Know


            Questions?

   Janey Barnes PhD | jbarnes@user-view.com
Jeff B...
Want to learn more?
• EMR Usability Principles and
  Proposed Testing
  • http://bit.ly/UsabilityHIMSS
• Checklist - Evalu...
ARRA & EMR Usability: What Providers Need to Know
ARRA & EMR Usability: What Providers Need to Know
ARRA & EMR Usability: What Providers Need to Know
Upcoming SlideShare
Loading in …5
×

ARRA & EMR Usability: What Providers Need to Know

3,109 views

Published on

What if US healthcare providers dramatically adopted EMRs in increasing numbers, worked hard to achieve meaningful use, but never benefited financially or in efficiency or quality?

Meaningful use will be dependent on adequate EMR usability. Discover how usability relates to a number of meaningful use criteria. We offer a usability checklist to assist providers in shopping for a new EMR, or to use during implementation of an existing EMR, in order to achieve efficiency, effectiveness, and usefulness.

Presentation to HIMSS 2010 with co-presenter Janey Barnes PhD.

1 Comment
6 Likes
Statistics
Notes
No Downloads
Views
Total views
3,109
On SlideShare
0
From Embeds
0
Number of Embeds
14
Actions
Shares
0
Downloads
177
Comments
1
Likes
6
Embeds 0
No embeds

No notes for slide

ARRA & EMR Usability: What Providers Need to Know

  1. 1. ARRA and EMR Usability What Providers Need to Know
  2. 2. Conflict of Interest Disclosure Jeff Belden MD Dr. Belden is on the faculty at University of Missouri - Columbia, which has a contractual consulting relationship with Cerner for EMR research and development. Dr. Belden has no financial interest.
  3. 3. Conflict of Interest Disclosure Janey Barnes PhD Contracted Research: • Allscripts, • Patagonia Health, • Duke Health Systems
  4. 4. Low EMR Adoption Rates
  5. 5. EMR Adoption Hospitals - 2008 100% Full Basi Basic without None c clinician notes AK Jha et al, NEJM 2009
  6. 6. EMR Adoption Doctor Offices – 2007-08 100% Full Basic None CM DesRoches et al, NEJM 2008
  7. 7. Why?
  8. 8. Barriers • Purchase price • Uncertain ROI • Lost productivity • Finding an EMR that meets needs • Obsolescence concerns
  9. 9. Usability missing Smelcer 2009
  10. 10. What is ^usability?
  11. 11. Usability is Effectiveness Efficiency Satisfaction ISO 2003
  12. 12. Usability means Learnable Efficient Memorable Error-free Satisfying Useit.com
  13. 13. Current EMRs lack good usability Smelcer 2009
  14. 14. examples
  15. 15. Time consuming dictation takes 33 seconds EMR can take 10x longer
  16. 16. Alert Fatigue of high-priority DDI alerts… 90% ignored
  17. 17. Complex steps hard to learn Longer, costly training
  18. 18. AAFP EMR Survey 2009 User satisfaction ratings from 2,012 Family Physicians
  19. 19. Usability is…
  20. 20. 10 Principles 1. Simplicity 7. Feedback 2. Naturalness 8. Effective use of 3. Consistency language 4. Minimizing cognitive 9. Effective information load presentation 5. Efficient interactions 10.Preservation of 6. Forgiveness context http://bit.ly/UsabilityHIMSS
  21. 21. Simplicity
  22. 22. Simplicity For doing refills For overview only
  23. 23. Naturalness
  24. 24. Naturalness Old way – lots of drill-down clicking
  25. 25. Naturalness Better way we know the body already
  26. 26. Consistency
  27. 27. Consistency Name and identifying info consistently placed
  28. 28. Minimizing Cognitive Load
  29. 29. Minimizing Cognitive Load Exact past dates • This requires mental math
  30. 30. Minimizing Cognitive Load Relative past dates • Easier. No extra thinking.
  31. 31. Minimizing Cognitive Load Hover to see more detail • Have it both ways
  32. 32. Efficient Interactions
  33. 33. Efficient Interactions Dashboard efficiency
  34. 34. Efficient Interactions 50 Clicks… • 6 minutes
  35. 35. Efficient Interactions 2 Clicks… • 1-2 minutes
  36. 36. Efficient Interactions Dashboard benefits • Single visual plane • No navigation away needed • No need to recall last screen’s content • Use hover-over, or pop-up windoids
  37. 37. Efficient Interactions Dashboard principle Show me WINWINIANM (what I need, when I need it, and nothing more)
  38. 38. Forgiveness
  39. 39. Forgiveness Let users discover by exploring without fear of destroying Let users recover gracefully from mistakes
  40. 40. Forgiveness A bad example…
  41. 41. Feedback
  42. 42. Feedback • Don’t keep the user wondering • Show expected delays • Confirm changes that aren’t evident
  43. 43. Feedback Imagine this scenario • Imagine a user clicks a page element, and a long, slow database call ensues…
  44. 44. Acceptable
  45. 45. Better Please wait while we check 10,357 records…
  46. 46. Best Time remaining… 8 seconds Please wait while we check 10,357 records…
  47. 47. Effective Use of Language
  48. 48. Terse for doctor Plain English for patient
  49. 49. Effective Information Presentation
  50. 50. Effective Information Presentation Sorted alphabetically, not randomly Better yet, allow sort by other criteria, t
  51. 51. Preservation of Context
  52. 52. Preservation of Context
  53. 53. ARRA’s Meaningful Use Matrix Where does usability fit in?
  54. 54. Meaningful Use (MU) 5 Health Outcome Policy Priorities 1. Improve quality, safety, efficiency, & reduce health disparities 2. Engage patients & families 3. Improve care coordination 4. Improve population & public health 5. Ensure adequate privacy & security protections for personal health information
  55. 55. Meaningful Use (MU) We picked 3 1. Improve quality, safety, efficiency, & reduce health disparities 2. Engage patients & families 3. Improve care coordination 4. Improve population & public health 5. Ensure privacy & security protections for personal health information
  56. 56. MU > Improve Quality 1. Improve Quality… 1. Evidence-based CPOE 2. Clinical decision support at the Point-of- care 3. Registries for patient outreach
  57. 57. MU > Quality > EBM CPOE Evidence-based CPOE …building ruts to quality & safety examples…
  58. 58. MU > Quality > EBM CPOE Antibiotic Selection for Community-Acquired Pneumonia Usability principles 1. Simplicity 2. Efficient interactions 3. Minimizing cognitive load
  59. 59. MU > Quality > EBM CPOE
  60. 60. MU > Quality > EBM CPOE > Simplicity Simplicity
  61. 61. MU > Quality > EBM CPOE > Min cognitive load Minimize cognitive load
  62. 62. MU > Quality > EBM CPOE > Efficient Efficient interactions
  63. 63. MU > Quality > CDS at POC Clinical Decision Support at the Point of Care examples…
  64. 64. MU > Quality > CDS at POC > Problem List Problem Lists Usability principles 1. Simplicity 2. Naturalness 3. Effective use of language 4. Effective information presentation
  65. 65. MU > Quality > CDS at POC > Problem List > Simplicity Simplicity
  66. 66. MU > Quality > CDS at POC > Problem List > Simplicity The old way...
  67. 67. MU > Quality > CDS at POC > Problem List > Simplicity Better way
  68. 68. MU > Quality > CDS at POC > Problem List > Naturalness Naturalness Sort & sequence like clinicians think Not by diagnosis code.. … but alphabetically
  69. 69. MU > Quality > CDS at POC > Problem List > Naturalness Effective use of language Common ways you could display Diabetes 250.00 (ICD-9) Just use words physicians use What would Dr. Jesus say?
  70. 70. MU > Quality > CDS at POC > Problem List > Info Prez Effective Info Presentation Sorted alphabetically Sorted for cardiology
  71. 71. MU > Quality > CDS at POC > Problem List > Info Prez Effective Info Presentation Highlighted for cardiology Filtered for cardiology
  72. 72. MU > Quality > CDS at POC > Alerts Alerts Usability principles 1. Simplicity 2. Efficiency 3. Effective information presentation
  73. 73. MU > Quality > CDS at POC > Alerts > Simplicity Too busy visually…
  74. 74. MU > Quality > CDS at POC > Alerts > Simplicity Try to find the essence…
  75. 75. MU > Quality > CDS at POC > Alerts > Simplicity All the doctor needs to see
  76. 76. MU > Quality > CDS at POC > Alerts > Simplicity Simplicity
  77. 77. MU > Quality > CDS at POC > Alerts > Info Presentation Effective info presentation Show only what the physician wants • Severity • What is the adverse effect? • Alternative actions
  78. 78. MU > Quality > CDS at POC > Alerts > Feedback Efficient interactions • Prevent repeated alerts for same combo • Prevent alerts for low-level danger • Let user adjust alert level
  79. 79. MU > Quality > CDS at POC > Lab Lab results Usability principles 1. Effective information presentation 2. Minimize cognitive load 3. Preservation of context
  80. 80. MU > Quality > CDS at POC > Lab > Info Presentation Effective info presentation old new
  81. 81. MU > Quality > CDS at POC > Lab > Min cognitive load Minimize cognitive load
  82. 82. MU > Quality > CDS at POC > Lab > Preserve context Preservation of context Compare to prior lab, two year graphical trend
  83. 83. MU > Quality > CDS at POC > Lab > Preserve context And what medication is he/she on? And what is the weight and BP doing?
  84. 84. MU > Quality > Registries Registries examples…
  85. 85. MU > Quality > CDS at POC > Problem List Quality Registry: Dashboard Usability principles 1. Efficient interactions 2. Effective information presentation
  86. 86. MU > Quality > Registries > Quality dashboard Diabetes quality dashboard
  87. 87. MU > Quality > Registries > Quality dashboard Efficient interactions Give actionable info at Point-of-Care
  88. 88. MU > Engaging Patients > Access to health record Engaging Patients Giving e-access to health records examples…
  89. 89. MU > Engage patients Clinical Summary Usability principles 1. Effective use of language 2. Efficient interactions
  90. 90. MU > Engage patients > Clinical summary Clinical Summary at Visit A take-home for the patient
  91. 91. MU > Engage patients > Clinical summary
  92. 92. MU > Engage patients > Clinical summary Effective Language Plain English
  93. 93. MU > Engage patients > Clinical summary Efficient And something for the wallet
  94. 94. MU > Engage patients > View lab on web Viewing lab results on web Usability principles 1. Effective use of language 2. Effective information presentation
  95. 95. MU > Engage patients > View lab on web Viewing lab results on web
  96. 96. MU > Engage patients > View lab on web Effective Language Change ”Reference” to ”Normal Range”
  97. 97. MU > Engage patients > View lab on web Effective info presentation What would patient expect to find? •Highlight unviewed results •Abnormal in color •Doctor’s annotations to explain
  98. 98. MU > Engage patients > View lab on web Effective Info Presentation Easy to misunderstand “which normal range”
  99. 99. MU > Engage patients > e-Copy Web Access or e-Copy Usability principles 1. Naturalness 2. Forgiveness
  100. 100. MU > Engage patients > e-Copy Naturalness
  101. 101. MU > Engage patients > e-Copy Forgiveness
  102. 102. EMR Buyer’s Guide Shopping for usability Before you buy, or implement…
  103. 103. MU > Before you buy It’s a process… Define what’s Important to You • Evaluate your alternatives • Select the alternative that is best for your team
  104. 104. MU > Before you buy What’s important to you Effectiveness •What do you want /need from your EMR? •How will this product meet those wants / needs? •See barriers when you try the product?
  105. 105. MU > Before you buy What’s important to you Efficiency •What outcomes should be better • Faster • more robust • have better payoff
  106. 106. MU > Before you buy What’s important to you Satisfaction •Of which users? •For which key tasks? •In which clinical setting or environment?
  107. 107. MU > Before you buy Evaluate Your Alternatives What do your friends say • Ask, ask, ask! • Go watch your friends at work on their EMR • with their actual patients. • not a demo in the office. • watch others while you are there.
  108. 108. MU > Before you buy Evaluate Your Alternatives What do your colleagues say • Blogs, etc. What do your professional groups & others say • KLAS • AAFP • Your state’s academy of …
  109. 109. MU > Before you buy Evaluate Your Alternatives What do you and your team say • Do your own evaluation • Create 3-5 primary care clinical scenarios • Time critical tasks in those scenarios • Set targets that you want • A few users rate qualitative aspects of the software with 5-point scale • Evaluate reporting functions
  110. 110. MU > Before you buy Creating Clinical Scenarios 1.Choose ones that matter • frequent, important • Include prescribing • Include “hey-doc” request 2.Test them 3.Look for efficiencies • e.g. document normal ROS with one click
  111. 111. MU > Before you buy Buyer Beware Try Out the Reporting Function • What will you want to report? • A1Cs in diabetics • BP control rates in hypertension • List of patients on a particular recalled drug • Should be easy • Look for efficiencies • Out of the box experience • Easy to make reports quickly
  112. 112. MU > Before you buy Buyer Beware Don’t be “wowed” by Templates Don’t be impressed with installed templates • Try them out first • Try to make one yourself (with no training) Don’t expect clinicians to create or edit • Try to make some • Ideal: Easy to make on the fly. • Even a caveman (a physician) can do it!
  113. 113. MU > Before you buy Buyer Beware Training • Touch on initial training • you & staff will be overwhelmed at launch • Demand later training • after you have the basics down
  114. 114. Want to learn more? • EMR Usability Principles and Proposed Testing • http://bit.ly/UsabilityHIMSS • Checklist - Evaluating Usability in an EMR before you buy • http://bit.ly/shopEMR
  115. 115. ARRA & Usability: What Providers Need to Know Questions? Janey Barnes PhD | jbarnes@user-view.com Jeff Belden MD | beldenj@health.missouri.edu
  116. 116. Want to learn more? • EMR Usability Principles and Proposed Testing • http://bit.ly/UsabilityHIMSS • Checklist - Evaluating Usability in an EMR before you buy • http://bit.ly/shopEMR Janey Barnes PhD | jbarnes@user-view.com Jeff Belden MD | beldenj@health.missouri.edu

×