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- 1. ARRA and EMR Usability WhatProviders 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. Conflict of InterestDisclosure Janey Barnes PhD Contracted Research: • Allscripts, • Patagonia Health, • Duke Health Systems Crisis
- 3. Really big c oncern Low EMR Adoption Rates
- 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. Why? Barriers •Purchase price •Uncertain ROI •Lostproductivity •Finding an EMR that meets needs •Obsolescence concerns
- 6. Usability missing Smelcer 2009 EMR What is ^usability?
- 7. Usability is Effectiveness Efficiency Satisfaction ISO 2003 Usability means Learnable Efficient Memorable Error-free Satisfying Useit.com
- 8. Current EMRs lack goodusability Smelcer 2009 examples
- 9. Time consuming dictation takes33 seconds EMR can take 10x longer Alert Fatigue of high-priority DDI alerts… 90% ignored
- 10. Complex steps hard tolearn Longer, costly training AAFP EMR Survey 2009 User satisfaction ratings from 2,012 Family Physicians
- 12. Usability is… 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
- 13. Simplicity Simplicity For doing refills For overview only
- 14. Naturalness Naturalness Old way – lots of drill-down clicking
- 15. Naturalness Better way we knowthe body already Consistency
- 16. Consistency Name and identifyinginfo consistently placed Minimizing Cognitive Load
- 17. Minimizing Cognitive Load Exactpast dates • This requires mental math Minimizing Cognitive Load Relative past dates • Easier. No extra thinking.
- 18. Minimizing Cognitive Load Hoverto see more detail • Have it both ways Efficient Interactions
- 19. Efficient Interactions Dashboard efficiency Efficient Interactions 50 Clicks… • 6 minutes
- 20. Efficient Interactions 2 Clicks… • 1-2 minutes 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
- 21. Efficient Interactions Dashboard principle Showme WINWINIANM (what I need, when I need it, and nothing more) Forgiveness
- 22. Forgiveness Let users discoverby exploring without fear of destroying Let users recover gracefully from mistakes Forgiveness A bad example…
- 23. Feedback Feedback • Don’t keep the user wondering • Show expected delays • Confirm changes that aren’t evident
- 24. Feedback Imagine thisscenario • Imagine a user clicks a page element, and a long, slow database call ensues… Acceptable
- 25. Better Please wait while we check 10,357 records… Best Time remaining… 8 seconds Please wait while we check 10,357 records…
- 26. Effective Use ofLanguage Terse for doctor Plain English for patient
- 27. Effective Information Presentation EffectiveInformation Presentation Sorted alphabetically, not randomly Better yet, allow sort by other criteria, too
- 28. Preservation of Context Preservation of Context
- 29. ARRA’s Meaningful UseMatrix 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
- 30. 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 MU > Improve Quality 1. Improve Quality… 1. Evidence-based CPOE 2. Clinical decision support at the Point-of-care 3. Registries for patient outreach
- 31. 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
- 32. MU > Quality> EBM CPOE MU > Quality > EBM CPOE > Simplicity Simplicity
- 33. MU > Quality> EBM CPOE > Min cognitive load Minimize cognitive load MU > Quality > EBM CPOE > Efficient Efficient interactions
- 34. 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
- 35. MU > Quality> CDS at POC > Problem List > Simplicity Simplicity MU > Quality > CDS at POC > Problem List > Simplicity The old way...
- 36. 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 diagnosis code.. … but alphabetically
- 37. 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? MU > Quality > CDS at POC > Problem List > Info Prez Effective Info Presentation Sorted alphabetically Sorted for cardiology
- 38. MU > Quality> CDS at POC > Problem List > Info Prez Effective Info Presentation Highlighted for cardiology Filtered for cardiology MU > Quality > CDS at POC > Alerts Alerts Usability principles 1. Simplicity 2. Efficiency 3. Effective information presentation
- 39. MU > Quality> CDS at POC > Alerts > Simplicity Too busy visually… MU > Quality > CDS at POC > Alerts > Simplicity Try to find the essence…
- 40. MU > Quality> CDS at POC > Alerts > Simplicity All the doctor needs to see MU > Quality > CDS at POC > Alerts > Simplicity Simplicity
- 41. 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 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
- 42. MU > Quality> CDS at POC > Lab Lab results Usability principles 1. Effective information presentation 2. Minimize cognitive load 3. Preservation of context MU > Quality > CDS at POC > Lab > Info Presentation Effective info presentation old new
- 43. 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 graphical trend
- 44. 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…
- 45. MU > Quality> CDS at POC > Problem List Quality Registry: Dashboard Usability principles 1. Efficient interactions 2. Effective information presentation MU > Quality > Registries > Quality dashboard Diabetes quality dashboard
- 46. 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 health records examples…
- 47. MU > Engagepatients Clinical Summary Usability principles 1. Effective use of language 2. Efficient interactions MU > Engage patients > Clinical summary Clinical Summary at Visit A take-home for the patient
- 48. MU > Engagepatients > Clinical summary MU > Engage patients > Clinical summary Effective Language Plain English
- 49. MU > Engagepatients > 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 language 2. Effective information presentation
- 50. MU > Engagepatients > View lab on web Viewing lab results on web MU > Engage patients > View lab on web Effective Language Change ”Reference” to ”Normal Range”
- 51. MU > Engagepatients > View lab on web Effective info presentation What would patient expect to find? •Highlight unviewed results •Abnormal in color •Doctor’s annotations to explain MU > Engage patients > View lab on web Effective Info Presentation Easy to misunderstand “which normal range”
- 52. MU > Engagepatients > e-Copy Web Access or e-Copy Usability principles 1. Naturalness 2. Forgiveness MU > Engage patients > e-Copy Naturalness
- 53. MU > Engagepatients > e-Copy Forgiveness EMR Buyer’s Guide Shopping for usability Before you buy, or implement…
- 54. MU > Beforeyou buy It’s a process… Define what’s Important to You • Evaluate your alternatives • Select the alternative that is best for your team 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?
- 55. MU > Beforeyou buy What’s important to you Efficiency •What outcomes should be better • Faster • more robust • have better payoff MU > Before you buy What’s important to you Satisfaction •Of which users? •For which key tasks? •In which clinical setting or environment?
- 56. MU > Beforeyou 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 …
- 57. MU > Beforeyou 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 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
- 58. MU > Beforeyou 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 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!
- 59. MU > Beforeyou buy Buyer Beware Training • Touch on initial training • you & staff will be overwhelmed at launch • Demand later training • after you have the basics down
- 60. Want to learnmore? • EMR Usability Principles and Proposed Testing • http://bit.ly/UsabilityHIMSS • Checklist - Evaluating Usability in an EMR before you buy • http://bit.ly/shopEMR ARRA & Usability: What Providers Need to Know Questions? Janey Barnes PhD | jbarnes@user-view.com Jeff Belden MD | beldenj@health.missouri.edu
- 61. Want to learnmore? • 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