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July 14, 2010 Readers Write 8 Comments

Achieving EMR Usability in Today’s Complex Technology Market
By Odell Tuttle

As HIMSS began recognizing the importance of human/computer interaction, its EHR Usability Task Force developed the 11 principles of usability — a framework which provides methods of usability evaluation to measure efficiency and effectiveness, including patient safety. This framework is invaluable as many of today’s clinical systems do not provide adequate support due to poor interface design.

From multiple data interchange and reporting standards, to formatting and encoding standards, to clinical processes and procedures — not to mention the government organizations and legislation — the EMR domain is vast and complex. For hospitals looking to implement an EMR, it is important they choose a technology partner experienced with proven, tested, and used systems. For rural community hospitals, it becomes critical, because their needs are so unique.

The HIMSS 11 principles of usability is a valuable tool in the EMR selection process. A summary of the HIMSS usability principles include:

Everything from lack of visual clutter and concise information display to inclusion of only functionality that is needed to effectively accomplish tasks.

This refers to how automatically “familiar” and easy to use the application feels to the user.

External consistency primarily has to do with how much an application’s structure, interactions, and behaviors match a user’s experience with other software applications. An internally consistent application uses concepts, behavior, appearance, and layout consistently throughout.

Minimizing Cognitive Load
Clinicians in particular are almost always performing under significant time pressure and in environments bursting with multiple demands for their attention. Presenting all the information needed for the task at hand reduces cognitive load.

Efficient Interactions
One of the most direct ways to facilitate efficient user interactions is to minimize the number of steps it takes to complete tasks and to provide shortcuts for use by frequent and/or experienced users.

Forgiveness and Feedback
Forgiveness means that a design allows the user to discover it through exploration without fear of disastrous results. Good feedback to the user supports this goal by informing them about the effects of the actions they are about to take.

Effective Use of Language
All language used in an EMR should be concise and unambiguous.

Effective Information Presentation – Appropriate Density
While density of information on a screen is not commonly measured (though it can be), it is a very important concept to be cognizant of when designing EMR screens.

Meaningful Use of Color
Color is one of several attributes of visual communication. First and foremost, color should be used to convey meaning to the user.

Screen readability also is a key factor in objectives of efficiency and safety. Clinical users must be able to scan information quickly with high comprehension.

Preservation of Context
This is a very important aspect of designing a “transparent” application. In practical terms, this means keeping screen changes and visual interruptions to a minimum during completion of a particular task.

Reliable usability rating schemes offer product purchasers a tool for comparing products before purchase or implementation.

Making complex things appear simple is a very difficult job.  However, by utilizing the HIMSS 11 usability principles, healthcare providers are armed with a powerful tool in the EMR selection process.

Odell Tuttle is chief technology officer at Healthland.

Tech Talk and Market Strategy – Smart Phones
Mark Moffitt and Chris Reed

Tech Talk – Dictating Reports within an iPhone App

Good Shepherd Medical Center developed an iPhone app that has achieved a very high rate of adoption by physicians (95%) by providing a high degree of customization. The second most popular feature of the app is accessing and playing radiology dictation when a report has not been transcribed and is not available for viewing. Viewing lab data is first.

One reason this feature is popular is that it eliminates the need for a physician to call a dictation system and enter an ID, medical record number, etc., on a telephone keypad. Using the iPhone app. they simply press a virtual button to play a dictation on the iPhone. One less gadget a physician has to futz with.

It seemed logical that physicians would appreciate being able to record a dictation and view clinical results on the iPhone simultaneously without calling a dictation system and entering information on a telephone keypad.

Initially, we planned to integrate our iPhone app with a native dictation app. Unfortunately, this configuration requires multitasking to dictate while viewing clinical information on the iPhone. About one-half of the physicians using the app have the 3G phone. iPhone OS4 (operating system) supports multitasking but runs slow on 3G phones.

iPhone OS3.1.3, the latest OS designed for the 3G and 3GS, supports viewing Web pages while talking on the phone. We used this configuration to provide for the ability to dictate reports and view clinical results from an iPhone. Our iPhone web app uses the URL scheme “tel” to send commands to the iPhone phone app.

tel: <1>, <2>, <3>, <4>, <5> # note: “,” instructs phone to pause


1. Telephone number for the dictation system.

2. Physician id.    

3. Site id (hospital).  

4. Job type (H&P, discharge summary, progress note, etc.).

5. Medical record number.

The shortcoming of this approach is that the iPhone dials slowly the entries after the initial phone number. However, it is a big improvement over having a physician call the dictation system and enter information manually.

This is not our final solution. Sometime late this year or early next year when most physicians are using a 3GS or iPhone 4, we will switch to using a native app to dictate a report. If we had more resources, we would provide a version for iPhone OS3.1.3 and one for OS4.

Market Strategy – Smart Phones and EMRs

If the battlefield for winning the hearts and minds of physicians using electronic medical record (EMR) systems is shifting to smart phones and iPad-like devices, and I think it is, this trend may open the door for vendors like Meditech, Cerner, etc. to derail the Epic juggernaut.

Newer systems like Epic hold an advantage over older systems in terms of usability and user interface design. Software written for smart phones that operate over an underlying system can hide these flaws. It is possible, I contend, to neutralize Epic’s usability advantage over older systems among physicians using an “agile” smart phone software model. An agile model is one that puts in the hands of the customer the ability to rapidly modify and deploy smart phone software to fit the specific needs of an organization. This approach does not change the functionality of the underlying system.

Customers using agile smart phone software can:

1. Configure the app in different ways to greatly improve flow for different kinds of users, e.g. hospitalists, specialists, and surgeons; and for different types of smart phones.

2. Add data to the user interface to guide users toward a specific objective. For example, display house census, length of stay, observation patients and hours since admission, pending discharge, one touch icon for pending discharge alert, etc.

3. Add features that make the physicians work easier. Examples include one touch icon to call patient’s unit or nurse, play recording or dictate on the smart phone while viewing clinical results; access medication list directly from a PPM EMR without a patient master index between systems; receive clinical alerts; etc.

To compete, smart phone software must be core to your business. Give credit to Epic for recognizing the strategic value of their smart phone software. However, Epic’s smart phone software is “rigid” and that leaves them vulnerable to smart phone software that is agile.

Mark Moffitt is CIO and Chris Reed is Manager at Good Shepherd Medical Center in Longview, Texas.

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Currently there are "8 comments" on this Article:

  1. I appreciate Odell Tuttle’s reminders on the principles of good EHR usability.

    I would add another: the presentation of summary information in outputs (screens or paper) should be well organized, prioritized relative to clinical needs, and supportive in common clinical tasks – such as patient handoff or consultation.

    I’ve had the opportunity to review my mother’s computerized records printed out in paper from both ED and inpatient from several visits, and compare to the pure-paper records in a hospital where she has been readmitted.

    The former, from major EMR vendors whose names you’d instantly recognize, were painfully cryptic, disorganized, terse where detail was needed, detailed where pithiness was needed, and inappropriately atomized (related information disconnected in separate “silos”) to this physician.

    The “more primitive” paper records were concise, well organized, to the point, allowed me to review what was going on rapidly and without puzzlement, and from a clinician-to-clinician communication and information science perspectives, far superior to the legibnile gibberish from the electronic systems.

  2. ” For hospitals looking to implement an EMR, it is important they choose a technology partner experienced with proven, tested, and used systems. For rural community hospitals, it becomes critical, because their needs are so unique.”

    Why publish paragraphs of self-serving dribble. If every hospital implemented only technology that was “proven, tested, and used”, innovation and new, talented, competion would be effecitvely removed from the equation. Wasn’t it Billl Gates who once said “I don’t worry about IBM or any large vendor challenging us. I worry about some college kids in a basement somewhere developing the next great innovation.”

    Community hospitals often have less resources to provide similar services, but their needs are hardly “unique”. Acutely and chronically ill patients use them expecting the same quality of medical care, but often expect and receive a higher level of human care.

    Without newer products from emerging companies gaining a foothold in the marketplace, community hospitals can expect the same mediocrity being developed by the companies occupying this smaller market space for decades.

  3. Great info from Mr. Tuttle, and also the feedback.

    Unless the EMR purchaser is someone who can force physicians to adopt the ‘usable’ system, they also need to consider flexibility. This is especially true for users moving from paper to electronic for the first time. The vendor should have the ability to adapt to department-specific workflow and change requests that will start pouring in after the first physician begins documenting and discovering all the possibilities. An Adoptability Task Force might recommend these for starters:

    1. Physician Friendly – allow physicians to participate in the design of the documents they’ll be using. This minimizes training and increases ownership among users.

    2. Flexibility – form features/design options that allow a work-flow friendly design to meet the needs of various departments.

    3. Changeability- vendor tools that can turn around change requests and implement them within days or weeks instead of months

  4. @Chupacabra
    “. Physician Friendly – allow physicians to participate in the design of the documents they’ll be using. This minimizes training and increases ownership among users.”

    As Halamka has noted ( http://geekdoctor.blogspot.com/2008/02/provider-order-entry.html), and as a former clinician champion I must agree, most clinicians are time bankrupt and wont train (or, if mandated, will resent and resist training), before go live. clinicians want the software to work (be usable) out of the box, and will only seek/accept assistance at the elbow after go live. to me, EHR vendors should utilize clinician input by hiring clinicians to assist in developing the product before delivery. IMHO, expecting the client medical staff to “donate” their time (pre-go live) to help vendor make the loaded product more usable (usually in the form of questionable customization tweaks) is wasteful (to the client), and likely ineffective…althought the vendor may use this feedback towards usability in future iterations of it’s EHR, that will not help the client (though can certainlyl help the vendor, and maybe that is the business plan?)

  5. To continue on DZA’s comments — next generation EMR systems need NOT to require so many change requests. A well-designed system provides an a platform upon which the users can build a front-end that works for them. But the basic structure needs to be so good that changes are few. Multiple version control etc is so 1999 and is a nightmare that we need to wake up from.

    I also agree with MIMD that paper print-outs from many EMRs are ridiculous. Good design and testing should address this to make sure that a printout is equally as efficient and useable as the screen is.

  6. Pardon me but which agency is designated to assure that these devices are usable prior to purchase?

    Does any one actually think that the US Government will write checks for meeting the meaningful use rule?

  7. The usability goal of an EMR package should be take away the impression from the user that they are using a system to complete their activities. The system should let the user focus on their task and not on remembering the screens, clicks and keys. These are good guiding principles for designing such a system.

  8. Forwarded information below excerpted from HIMSS 6/10 internal newsletter:

    As this year’s HIMSS-MN Advocacy Chair, Sue Green participated in an Advocacy Roundtable to help set the focus of Fiscal Year 2010. Topics included better and meaningful communication of Health Care Reform progress and issues, discussing ways to use technology and promote adoption.

    Key support issues this year are:

    * HIMSS recommends that any future policy pertaining to the EMR incentive programs under ARRA (American Recovery and Investment Act) appropriately balance meaningful use criteria/measures with industry readiness without delaying the timeline for implementation since providers are struggling to implement adoption of EMR under the current deadlines;
    * HIMSS recommends that Congress enable the study of an informed patient identity solution. Conduct an analysis or study thru HHS (Health and Human Services) to weigh its value. As information technology (IT) makes deeper inroads in healthcare, and as health information exchanges (HIEs) and the Nationwide Health Information Network (NHIN) work to connect information locally, regionally, and nationally. Patient Identity (PI) integrity is a critical issue that must be addressed by policymakers.

    The study would analyze whether a single identifier makes sense? What would be the
    best type of identifier? Who controls it? What value is it to consumers? Then pilot the
    recommended approach and solution; and
    * HIMSS recommends that Congress work with the Obama Administration to make permanent the current physician self referral regulation exemptions (Stark exemptions) and anti-kickback safe harbors for EHRs. The physician self referral regulation exemptions (Stark exemptions) and anti-kickback safe harbors established in 2006 for electronic health records (EHRs); known as the “EHR Donation Rules”, expire in 2013. If the rules are not made permanent, providers will have new challenges in financing EHR’s to achieve the meaningful use of certified EHR technology and engage in the wide-scale electronic exchange of health information. Providers will also be less like to continue adoption of EHR’s without incentives.

    So members might ask the question, “Do our efforts through HIMSS or on ‘the hill’ make a difference?”

    The answer is “YES.”

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