This document discusses usability principles for electronic medical records (EMRs) and their role in meeting meaningful use criteria for stimulus funding. It outlines various usability issues with current EMRs like time-consuming tasks and alert fatigue. Ten key usability principles are described, including simplicity, naturalness, consistency and minimizing cognitive load. Examples are given of how these principles can be applied to EMR functions like clinical decision support, problem lists, labs, quality dashboards and patient engagement tools to improve efficiency, safety and care coordination.
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ARRA & EMR Usability: What Providers Need to KnowJeffery Belden
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.
Whether the user is interacting with a mobile device, a web site, or a phone-based health technology system, there is often a large gap between what the user wants to accomplish and how they want to accomplish it, and what they actually get from the system. The interface can be challenging and capturing any feedback or user interactions is difficult using on keyboards and point and click tools. Speech Recognition is changing this interaction by capturing the clinical input and allowing clinicians and healthcare users to access systems that listen and responds seamlessly understanding the context and the intent turning what the users wants into what they get.
Take a look at what makes an EMR usable. It’s more than user satisfaction. Learn how EMR Usability is getting more attention at the national level in certification, standards, research, and policy.
Closing keynote presentation at HIMSS 2010 Academic Forum in Atlanta GA.
Case Study "Dignity Health: Implementation of an EHR Alliance Bridging Acute and Ambulatory Care"
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Content redirector
1. 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
- Columbia, which has a contractual consulting
relationship with Cerner for EMR research and
development.
Dr. Belden has no financial interest.
2. Conflict of Interest Disclosure
Janey Barnes PhD
Contracted Research:
• Allscripts,
• Patagonia Health,
• Duke Health Systems
Crisis
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
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
29. 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
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 > Engage patients
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 > Engage patients > Clinical summary
MU > Engage patients > Clinical summary
Effective Language
Plain English
49. 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 language
2. Effective information presentation
50. 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”
51. 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
MU > Engage patients > View lab on web
Effective Info Presentation
Easy to misunderstand “which normal range”
52. MU > Engage patients > e-Copy
Web Access or e-Copy
Usability principles
1. Naturalness
2. Forgiveness
MU > Engage patients > e-Copy
Naturalness
53. MU > Engage patients > e-Copy
Forgiveness
EMR Buyer’s Guide
Shopping for usability
Before you buy, or implement…
54. 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
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 > Before you 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 > 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 …
57. 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
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 > 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
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 > 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
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
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 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