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Content redirector

  1. 1. ARRA andEMR UsabilityWhat Providers Need to Know 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.
  2. 2. Conflict of Interest Disclosure Janey Barnes PhD Contracted Research: • Allscripts, • Patagonia Health, • Duke Health SystemsCrisis
  3. 3. Really big c oncern Low EMR Adoption Rates
  4. 4. EMR Adoption Hospitals - 2008 100% Full Basic Basic without None clinician notes AK Jha et al, NEJM 2009 EMR Adoption Doctor Offices – 2007-08 100%Full Basic None CM DesRoches et al, NEJM 2008
  5. 5. Why?Barriers•Purchase price•Uncertain ROI•Lost productivity•Finding an EMR that meets needs•Obsolescence concerns
  6. 6. Usability missingSmelcer 2009 EMR What is ^usability?
  7. 7. Usability is Effectiveness Efficiency SatisfactionISO 2003Usability means Learnable Efficient Memorable Error-free SatisfyingUseit.com
  8. 8. Current EMRslack good usabilitySmelcer 2009 examples
  9. 9. Time consumingdictation takes 33 secondsEMR can take 10x longerAlert Fatigueof high-priority DDI alerts…90% ignored
  10. 10. Complex stepshard to learnLonger, costly trainingAAFP EMR Survey 2009User satisfaction ratingsfrom 2,012 Family Physicians
  11. 11. Usability is… 10 Principles1. Simplicity 7. Feedback2. Naturalness 8. Effective use of3. Consistency language4. Minimizing cognitive 9. Effective information load presentation5. Efficient interactions 10.Preservation of6. Forgiveness context http://bit.ly/UsabilityHIMSS
  12. 12. Simplicity SimplicityFor doing refillsFor overview only
  13. 13. Naturalness NaturalnessOld way – lots of drill-down clicking
  14. 14. NaturalnessBetter waywe know the bodyalready Consistency
  15. 15. ConsistencyName and identifying info consistently placed Minimizing Cognitive Load
  16. 16. Minimizing Cognitive LoadExact past dates• This requires mental math Minimizing Cognitive LoadRelative past dates• Easier. No extra thinking.
  17. 17. Minimizing Cognitive LoadHover to see more detail• Have it both ways Efficient Interactions
  18. 18. Efficient InteractionsDashboard efficiency Efficient Interactions50 Clicks… • 6 minutes
  19. 19. Efficient Interactions2 Clicks… • 1-2 minutes Efficient InteractionsDashboard benefits• Single visual plane• No navigation away needed• No need to recall last screen’s content• Use hover-over, or pop-up windoids
  20. 20. Efficient InteractionsDashboard principleShow me WINWINIANM (what I need, when I need it, and nothing more) Forgiveness
  21. 21. ForgivenessLet users discover byexploring without fear of destroyingLet users recover gracefully frommistakes Forgiveness A bad example…
  22. 22. Feedback Feedback• Don’t keep the user wondering• Show expected delays• Confirm changes that aren’t evident
  23. 23. Feedback Imagine this scenario • Imagine a user clicks a page element, and a long, slow database call ensues…Acceptable
  24. 24. Better Please wait while we check 10,357 records…Best Time remaining… 8 seconds Please wait while we check 10,357 records…
  25. 25. Effective Use of LanguageTerse for doctorPlain English for patient
  26. 26. Effective Information PresentationEffective Information PresentationSorted alphabetically, not randomly Better yet, allow sort by other criteria, too
  27. 27. Preservation of Context Preservation of Context
  28. 28. ARRA’s Meaningful Use Matrix Where does usability fit in?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
  29. 29. 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 informationMU > Improve Quality 1. Improve Quality… 1. Evidence-based CPOE 2. Clinical decision support at the Point-of-care 3. Registries for patient outreach
  30. 30. MU > Quality > EBM CPOE Evidence-based CPOE …building ruts to quality & safety examples…MU > Quality > EBM CPOE Antibiotic Selection for Community-Acquired Pneumonia Usability principles 1. Simplicity 2. Efficient interactions 3. Minimizing cognitive load
  31. 31. MU > Quality > EBM CPOEMU > Quality > EBM CPOE > Simplicity Simplicity
  32. 32. MU > Quality > EBM CPOE > Min cognitive load Minimize cognitive loadMU > Quality > EBM CPOE > Efficient Efficient interactions
  33. 33. MU > Quality > CDS at POC Clinical Decision Support at the Point of Care examples…MU > Quality > CDS at POC > Problem List Problem Lists Usability principles 1. Simplicity 2. Naturalness 3. Effective use of language 4. Effective information presentation
  34. 34. MU > Quality > CDS at POC > Problem List > Simplicity SimplicityMU > Quality > CDS at POC > Problem List > Simplicity The old way...
  35. 35. MU > Quality > CDS at POC > Problem List > Simplicity Better wayMU > Quality > CDS at POC > Problem List > NaturalnessNaturalness Sort & sequence like clinicians think Not by diagnosis code.. … but alphabetically
  36. 36. MU > Quality > CDS at POC > Problem List > NaturalnessEffective use of language Common ways you could display Diabetes 250.00 (ICD-9) Just use words physicians use What would Dr. Jesus say?MU > Quality > CDS at POC > Problem List > Info PrezEffective Info PresentationSorted alphabetically Sorted for cardiology
  37. 37. MU > Quality > CDS at POC > Problem List > Info PrezEffective Info PresentationHighlighted for cardiology Filtered for cardiologyMU > Quality > CDS at POC > Alerts Alerts Usability principles 1. Simplicity 2. Efficiency 3. Effective information presentation
  38. 38. MU > Quality > CDS at POC > Alerts > Simplicity Too busy visually…MU > Quality > CDS at POC > Alerts > Simplicity Try to find the essence…
  39. 39. MU > Quality > CDS at POC > Alerts > Simplicity All the doctor needs to seeMU > Quality > CDS at POC > Alerts > Simplicity Simplicity
  40. 40. MU > Quality > CDS at POC > Alerts > Info Presentation Effective info presentation Show only what the physician wants • Severity • What is the adverse effect? • Alternative actionsMU > 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
  41. 41. MU > Quality > CDS at POC > Lab Lab results Usability principles 1. Effective information presentation 2. Minimize cognitive load 3. Preservation of contextMU > Quality > CDS at POC > Lab > Info Presentation Effective info presentation old new
  42. 42. MU > Quality > CDS at POC > Lab > Min cognitive load Minimize cognitive loadMU > Quality > CDS at POC > Lab > Preserve context Preservation of context Compare to prior lab, two year graphical trend
  43. 43. MU > Quality > CDS at POC > Lab > Preserve context And what medication is he/she on? And what is the weight and BP doing?MU > Quality > Registries Registries examples…
  44. 44. MU > Quality > CDS at POC > Problem List Quality Registry: Dashboard Usability principles 1. Efficient interactions 2. Effective information presentationMU > Quality > Registries > Quality dashboard Diabetes quality dashboard
  45. 45. MU > Quality > Registries > Quality dashboard Efficient interactions Give actionable info at Point-of-CareMU > Engaging Patients > Access to health record Engaging Patients Giving e-access to health records examples…
  46. 46. MU > Engage patients Clinical Summary Usability principles 1. Effective use of language 2. Efficient interactionsMU > Engage patients > Clinical summary Clinical Summary at Visit A take-home for the patient
  47. 47. MU > Engage patients > Clinical summaryMU > Engage patients > Clinical summary Effective Language Plain English
  48. 48. MU > Engage patients > Clinical summary Efficient Andsomething for the walletMU > Engage patients > View lab on web Viewing lab results on web Usability principles 1. Effective use of language 2. Effective information presentation
  49. 49. MU > Engage patients > View lab on web Viewing lab results on webMU > Engage patients > View lab on web Effective Language Change ”Reference” to ”Normal Range”
  50. 50. 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 explainMU > Engage patients > View lab on web Effective Info Presentation Easy to misunderstand “which normal range”
  51. 51. MU > Engage patients > e-Copy Web Access or e-Copy Usability principles 1. Naturalness 2. ForgivenessMU > Engage patients > e-Copy Naturalness
  52. 52. MU > Engage patients > e-Copy Forgiveness EMR Buyer’s Guide Shopping for usability Before you buy, or implement…
  53. 53. 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 teamMU > 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?
  54. 54. MU > Before you buy What’s important to you Efficiency •What outcomes should be better • Faster • more robust • have better payoffMU > Before you buy What’s important to you Satisfaction •Of which users? •For which key tasks? •In which clinical setting or environment?
  55. 55. 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.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 …
  56. 56. 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 functionsMU > 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
  57. 57. 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 quicklyMU > 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!
  58. 58. 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
  59. 59. 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/shopEMRARRA & Usability: What Providers Need to Know Questions? Janey Barnes PhD | jbarnes@user-view.comJeff Belden MD | beldenj@health.missouri.edu
  60. 60. 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

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