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

Objectives

1. Define usability2. List up to 10 principles of EMR usability3. List usability requirements for “meaningful

use”4. Use a checklist when looking for usability

in an EMR

What is usability?

Usability

• It’s not just “user satisfaction”

Usability is

• Effectiveness• Efficiency• Satisfaction

– Specific users– Specific set of tasks– Particular environment

Usability is

• Effectiveness• Efficiency• Satisfaction

– Specific users– Specific set of tasks– Particular environment

Usability is

• Effectiveness• Efficiency• Satisfaction

– Specific users– Specific set of tasks– Particular environment

Usability is

• Effectiveness• Efficiency• Satisfaction

– Specific users– Specific set of tasks– Particular environment

5 Es of Usability

• Effective• Efficient• Engaging• Error tolerant• Easy to learn

Can usability be measured?

Yes it can

Counterpoint

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

Chilmarkchilmarkresearch.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

Simplicity

For doing refills

For overview only

Simplicity• User: Surgeon• Task: Rounding

Minimize Cognitive LoadDon’t make me think

Exact past dates• This requires mental math

Relative past dates• Easier. No extra thinking.

Hover to see more detail• Have it both ways

EfficiencyThe most measurable

Efficiency – How Fast?

• Time to finish tasks• Click count• Other measures using Morae

Dashboard efficiency

50 Clicks…• 6 minutes

…2 Clicks• 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

Hover Tool-tip

Windoid pop-up

Dashboard principle

Show me WINWINIANM

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

ForgivenessError tolerance

ForgivenessLet users recover gracefully from mistakes

Feedback

Feedback

• 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…

Acceptable

Better

Please wait while we check 10,357 records…

Best

Please wait while we check 10,357 records…

Time remaining… 8 seconds

Poor

• 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 of Language

• Be terse• First words are critical

First words matter

Wrong sequenceCulture, blood, peripheralCulture, blood, central lineCulture, urine, catheterCulture, urine, clean-voided

Better sequenceBlood , peripheral (culture)Blood, central line (culture)Urine, catheter (culture)Urine, clean-voided (culture)

Effective Information Presentation

Information presentationVertical text harder to read

Information presentationHorizontal text easier to read.

Takes up same space.

Naturalness

Naturalness

• 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

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

David Blumenthal MD MPP | ONCHIT

… 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…“

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)

Make a shopping list

1. Create clinical scenarios to test2. Time critical tasks

– Set targets (6 clicks for simple acute illness)– # of clicks, time to complete task

3. Have your group do qualitative ratings– Use some of our 10 principles

4. Test the EMRs reporting function

Creating clinical scenarios

1. Choose ones that matter1. common, important2. Include prescribing3. Include “hey-doc” request

2. Test them3. 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

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

Still need help?

• Use our online shopping checklist

• http://bit.ly/shopEMR

Want to learn more?

• 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

Thanks• HIMSS EMR Usability Task Force• Authors

– Janey Barnes PhD– Rebecca Grayson– Jeff Belden MD

• Team Leaders– Penn White MD– Tiana Thomas

Questions?