Has no real or apparent conflicts of interest to report. Conflict of Interest Disclosure Jeff Belden MD

Understanding the Landscape of EMR Usability Implications for ARRA and Beyond

Jeff Belden MD Associate Professor of Clinical Family Medicine University of Missouri - Columbia Chair – HIMSS Task Force on EMR Usability

Associate Professor of Clinical Family Medicine

University of Missouri - Columbia

Chair – HIMSS Task Force on EMR Usability

Objectives Define usability List up to 10 principles of EMR usability List usability requirements for “meaningful use” Use a checklist when looking for usability in an EMR

Define usability

List up to 10 principles of EMR usability

List usability requirements for “meaningful use”

Use a checklist when looking for usability in an EMR

What is usability?

Usability It’s not just “user satisfaction”

It’s not just “user satisfaction”

Usability is Effectiveness Efficiency Satisfaction Specific users Specific set of tasks Particular environment

Effectiveness

Efficiency

Satisfaction

Specific users

Specific set of tasks

Particular environment

Usability is Effectiveness Efficiency Satisfaction Specific users Specific set of tasks Particular environment

Effectiveness

Efficiency

Satisfaction

Specific users

Specific set of tasks

Particular environment

Usability is Effectiveness Efficiency Satisfaction Specific users Specific set of tasks Particular environment

Effectiveness

Efficiency

Satisfaction

Specific users

Specific set of tasks

Particular environment

Usability is Effectiveness Efficiency Satisfaction Specific users Specific set of tasks Particular environment

Effectiveness

Efficiency

Satisfaction

Specific users

Specific set of tasks

Particular environment

5 E s of Usability Effective Efficient Engaging Error tolerant Easy to learn

Effective

Efficient

Engaging

Error tolerant

Easy to learn

Can usability be measured? Yes it can

Yes it can

Counterpoint “ User friendly? There is simply no way you can certify such – end of story.” Chilmark chilmarkresearch.com

“ User friendly? There is simply no way you can certify such – end of story.”

Chilmark

chilmarkresearch.com

10 Principles of Usability Simplicity Naturalness Consistency Minimizing cognitive load Efficient interactions Forgiveness Feedback Effective use of language Effective information presentation Preservation of context

Simplicity

Naturalness

Consistency

Minimizing cognitive load

Efficient interactions

Forgiveness

Feedback

Effective use of language

Effective information presentation

Preservation of context

Simplicity

Simplicity For doing refills For overview only

For doing refills

For overview only

Simplicity User: Surgeon Task: Rounding

User: Surgeon

Task: Rounding

Minimize Cognitive Load Don’t make me think

Exact past dates This requires mental math

This requires mental math

Relative past dates Easier. No extra thinking.

Easier. No extra thinking.

Hover to see more detail Have it both ways

Have it both ways

Efficiency The most measurable

Efficiency – How Fast? Time to finish tasks Click count Other measures using Morae

Time to finish tasks

Click count

Other measures using Morae

Dashboard efficiency

50 Clicks… 6 minutes

6 minutes

… 2 Clicks 1-2 minutes

1-2 minutes

Dashboard benefits Single visual plane No navigation away needed No need to recall last screen’s content Use hover-over, or pop-up windoids

Single visual plane

No navigation away needed

No need to recall last screen’s content

Use hover-over, or pop-up windoids

Hover Tool-tip

Windoid pop-up

Dashboard principle Show me WINWINIANM (what I need, when I need it, and nothing more)

Show me WINWINIANM

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

Forgiveness Error tolerance

Forgiveness Let users recover gracefully from mistakes

Let users recover gracefully from mistakes

Feedback

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

Don’t keep the user wondering

Show expected delays

Confirm changes that aren’t evident

Feedback Imagine a user clicks a page element, and a long, slow database call ensues…

Imagine a user clicks a page element, and a long, slow database call ensues…

Acceptable

Better Please wait while we check 10,357 records…

Please wait while we check 10,357 records…

Best Please wait while we check 10,357 records… Time remaining… 8 seconds

Please wait while we check 10,357 records…

Poor Nothing changes visibly What does the user think? Should I click again? Did the application lock up?

Nothing changes visibly

What does the user think?

Should I click again?

Did the application lock up?

Effective Use of Language

Use of Language Use the user’s natural language Physician and nurse words both overlap and diverge Managers speak non-clinical language

Use the user’s natural language

Physician and nurse words both overlap and diverge

Managers speak non-clinical language

Use of Language Be terse First words are critical

Be terse

First words are critical

First words matter Wrong sequence Culture, blood, peripheral Culture, blood, central line Culture, urine, catheter Culture, urine, clean-voided Better sequence Blood , peripheral (culture) Blood, central line (culture) Urine, catheter (culture) Urine, clean-voided (culture)

Wrong sequence

Culture, blood, peripheral

Culture, blood, central line

Culture, urine, catheter

Culture, urine, clean-voided

Better sequence

Blood , peripheral (culture)

Blood, central line (culture)

Urine, catheter (culture)

Urine, clean-voided (culture)

Effective Information Presentation

Information presentation Vertical text harder to read

Information presentation Horizontal text easier to read. Takes up same space.

Naturalness

Naturalness Feels familiar Like real world Works like the web Easy to learn

Feels familiar

Like real world

Works like the web

Easy to learn

ARRA Usability Requirements for “meaningful use”

What ARRA has to say about usability nothing

nothing

So why should you care? 90 % of doctors surveyed said they are either “concerned” or “very concerned” about usability as a leading obstacle to EHR adoption. Nuance survey, June 2009 90 % concerned about usability

90 % of doctors surveyed said they are either “concerned” or “very concerned” about usability as a leading obstacle to EHR adoption.

Nuance survey, June 2009

David Blumenthal MD MPP | ONCHIT … many certified EHRs [not] user-friendly … “ … many certified EHRs [not] user-friendly … “

… many certified EHRs [not] user-friendly …

[CCHIT will] pilot test a 'first step' basic usability assessment program … “ [CCHIT will] pilot test a 'first step' basic usability assessment program … “

[CCHIT will] pilot test a 'first step' basic usability assessment program …

Shopping for EMR? Here are some tips

No online stores yet

Ratings Available but restricted KLAS (for users who rated their own) AAFP (Family Physician members only)

Available but restricted

KLAS (for users who rated their own)

AAFP (Family Physician members only)

Make a shopping list Create clinical scenarios to test Time critical tasks Set targets (6 clicks for simple acute illness) # of clicks, time to complete task Have your group do qualitative ratings Use some of our 10 principles Test the EMRs reporting function

Create clinical scenarios to test

Time critical tasks

Set targets (6 clicks for simple acute illness)

# of clicks, time to complete task

Have your group do qualitative ratings

Use some of our 10 principles

Test the EMRs reporting function

Creating clinical scenarios Choose ones that matter common, important Include prescribing Include “hey-doc” request Test them Look for efficiencies (e.g. document normal ROS with one click?)

Choose ones that matter

common, important

Include prescribing

Include “hey-doc” request

Test them

Look for efficiencies

(e.g. document normal ROS with one click?)

Try out 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 Out of the box, or Easy to make quickly

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

Out of the box, or

Easy to make quickly

Don’t be “wowed” by templates Don’t be impressed with installed templates Try them out first! Don’t expect clinicians to create or edit Try to make some Ideal: easy to make on the fly

Don’t be impressed with installed templates

Try them out first!

Don’t expect clinicians to create or edit

Try to make some

Ideal: easy to make on the fly

Still need help? Use our online shopping checklist http://bit.ly/shopEMR

Use our online shopping checklist

http://bit.ly/shopEMR

Want to learn more? Read more about principles & methods of testing http://bit.ly/UsabilityHIMSS

Read more about principles & methods of testing

http://bit.ly/UsabilityHIMSS

Want to learn more? How to do simple usability testing http://bit.ly/lo4Wn

How to do simple usability testing

http://bit.ly/lo4Wn

Thanks HIMSS EMR Usability Task Force Authors Janey Barnes PhD Rebecca Grayson Jeff Belden MD Team Leaders Penn White MD Tiana Thomas

HIMSS EMR Usability Task Force

Authors

Janey Barnes PhD

Rebecca Grayson

Jeff Belden MD

Team Leaders

Penn White MD

Tiana Thomas

Questions?