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.
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.