I've talked since the start of this blog about the importance of improving "Usability" for Electronic Medical Records (EMRs), and this post is an update which provides a single collection of relevant information:
First, a report raises growing concerns that electronic health record products are being developed without specific best practices and design standards related to EHR product use in a healthcare setting. To overcome this difficulty, many vendors support an independent body guiding development of voluntary usability standards for EHRs, the study found.
Second, here are two stories on the recent debate about how Usability should be part of EHR Certification - one is from Healthcare IT News, the other from CMIO.net.
Third, a Comparison of Questionnaires for Assessing Website Usability - while this is not healthcare specific, it provides some insight into Usability testing.
Other Links of Interest
• The HIMSS WhitePaper on EMR Usability
-- This paper is a very well done introduction and review of this topic, so definitely a good place to start. Or if you want the very short version, here is an HISTalk Reader post (kudos to Odell Tuttle) which summarizes the 11 HIMSS EHR Usability Principles as follows:
Simplicity
Everything from lack of visual clutter and concise information display to inclusion of only functionality that is needed to effectively accomplish tasks.
Naturalness
This refers to how automatically “familiar” and easy to use the application feels to the user.
Consistency
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.
Readability
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.
• Some excellent posts from John Halamka on this subject:
-- EHR Usability
-- Top 10 Barriers to EHR Implementation
• Improving Usability of Health IT for Physicians
-- A great article in Healthcare Informatics which starts by pointing out that most health professionals do not use available health IT systems because they actually increase their work effort and can too frequently hurt quality, whereas the objective should be to help physicians decrease their work effort while increasing their quality consistently. They offer thoughts on a "physician-specific point-of-care system that continuously adapts to practice patterns that could result in dramatic improvements to the quality and efficiency of healthcare delivery".
• Some past posts from me on this subject which I love so much!
-- The Dark Side of EHRs: Explores the issue of unintended consequences, often due to poor usability.
-- Good software includes superb usability: Discussion about how EMR vendors need to improve how they create their products.
-- Improving EMRs: Usability, Usability, Usability: My first ever blog post, the name speaks for itself.
And in case anyone is interested in "building a better mousetrap" - the charitable endeavor I manage, the Szollosi Healthcare Innovation Program (www.TheSHIPHome.org), is sponsoring one of the inaugural challenges in The Health 2.0 Developer Challenge. Our specific challenge is to rethink how we document in EMRs by using publicly available blog or wiki software to create a longitudinal medical record that represents a patient's multi-day hospital stay, or a multi-year relationship with a physician in the outpatient setting.
* NEW ADDITIONS *
* July, 2010: Usability in Health IT: Technical Strategy, Research, and Implementation (National Institute of Standards and Technology Conference) - this actually has about 20 different presentations on this topic.
* Sept, 2010: I presented at the Mayo Center's Innovation Conference about the need to rethink how we use computers in healthcare and shift from EMR 1.0 to EMR 2.0. Full blog is online at: http://drlyle.blogspot.com/2010/09/mayo-clinic-center-for-innovation-2010.html
* Nov, 2010: Incorporating Health IT into Workflow Redesign, prepared by the University of Wisconsin-Madison’s Center for Quality and Productivity Improvement (CQPI): or PDF of full summary: http://healthit.ahrq.gov/workflowfinalreport
* Nov, 2010: From NIST (and Usability expert Bob Schumacher), as report entitled "Customized Common Industry Format Template for Electronic Health Record Usability Testing" (PDF)
* Dec, 2010: The Usability Toolkit is a collection of forms, checklists and other useful documents for conducting usability tests and user interviews.
* Feb, 2011: Promoting Usability in Health Organizations: Initial Steps and Progress Toward a Healthcare Usability Maturity Model (HIMSS White Paper)
* March, 2012: NIST releases EHR usability guidance. The three-step protocol includes: Analyzing the EHR system's functionality; Conducting an expert review of the EHR system; and Performing validation testing of the user interface. According to NIST, the protocol assesses whether the EHR system can: Contain, collect and display the correct information; Ensure that users understand the information; and Allow users to easily locate needed information.
* August, 2012: A Long Way to Go for EMR Usability: Updates, Trends and Recommendations
Sunday, July 11, 2010
Our Healthcare System: Update
A variety of websites and stories which I found to be important or at least thought-provoking:
Key Web sites
• http://healthcareforamericanow.org/
-- The best site I have found to simply explain, "What does the new health reform law mean for YOU?"
• http://www.healthcare.gov/
-- The federal government's site that includes specific advice on how to find health insurance and how that is impacted by the new health reform law.
Healthcare IT stories
• Use of HIT Improves the Quality of Care
-- A Kaiser Permanente Study Finds Quality of Care Scores Increase as Patients and Physicians Communicate via Secure E-mail.
• Improving Usability of Health IT for Physicians
-- A great article in Healthcare Informatics which starts by pointing out that most health professionals do not use available health IT systems because they actually increase their work effort and can too frequently hurt quality, whereas the objective should be to help physicians decrease their work effort while increasing their quality consistently. They offer thoughts on a "physician-specific point-of-care system that continuously adapts to practice patterns that could result in dramatic improvements to the quality and efficiency of healthcare delivery".
General Healthcare Stories
• Process improvement to improve compliance with specialty visits
-- Turns out that when a PCP refers a patient to a specialist, they only make the appointment 70% of the time, and of those - only 70% show up - thus less than 50% of people go to the specialists when they are referred! This article talks about how a process improvement improved those metrics. Our medical group (www.NMPG.com) does something similar to help with this process and we believe it provides a higher quality and more efficient process for sure!
• Better ways to manage the flood of test results
-- New recommendations target how physicians and hospitals can best communicate test results and prevent harm to patients.
• Aftercare Tips for Patients Checking Out of the Hospital
-- NY Times article on how good discharge planning can keep patients from needing to be re-admitted after leaving a hospital, and could save Medicare billions.
• How the Performance of the U.S. Health Care System Compares Internationally (2010 Update)
-- Yet another report, placing the US healthcare system last among industrialized nations. US spends $7,300 per person per year on healthcare and gets the worst results. UK spends $3,000, New Zealand $2,500; Canada $3,900; Australia $3,400.
• Health overhaul may mean longer ER waits, crowding
-- Due to a shortage of primary care physicians (PCPs), Emergency Rooms may grow even more crowded with longer wait times under the nation's new health law since there will be many more patients with insurance, but no increase in PCPs.
• The Variability of Patient Care - by John Glaser
-- One of the smartest guys in healthcare explains the theory from one of my favorite books (Designing Care by Richard Bohmer),which I talked about in a previous post about Checklists and process improvement. The key point being that there are two classes of care in a hospital and in a physician's practice, and the importance of understanding that these two very diverse scenarios need to be recognized when designing process/workflows for care (especially including use of EHRs). Glaser explains further;
---- Sequential care is a form of production: It involves performing well-understood tasks in a well-understood sequence (e.g. routine heart surgery). Sequential care's mental image is that of a production line. With sequential care it is possible to engineer a preferred sequence of steps and have the EHR guide the care team in performing these steps. And it should be quite possible to measure the outcomes of these steps. (This is similar to Clay Christensen's Value Added Process)
---- Iterative care is a form of discovery: It addresses complex diagnoses and conditions for which the diagnosis and treatment are a repeating series of hypothesis-test/treat-revise hypothesis steps. Iterative care is different. The mental image should not be the factory floor but a group of scientists in the laboratory. In this scenario we must encourage collaboration, enable an unpredictable set of actions to be taken, and provide easy access to information and other experts that might help the team form and test hypotheses. Measuring the outcome of discovery is very difficult. (This is similar to Clay Christensen's Solution Shops)
Key Web sites
• http://healthcareforamericanow.org/
-- The best site I have found to simply explain, "What does the new health reform law mean for YOU?"
• http://www.healthcare.gov/
-- The federal government's site that includes specific advice on how to find health insurance and how that is impacted by the new health reform law.
Healthcare IT stories
• Use of HIT Improves the Quality of Care
-- A Kaiser Permanente Study Finds Quality of Care Scores Increase as Patients and Physicians Communicate via Secure E-mail.
• Improving Usability of Health IT for Physicians
-- A great article in Healthcare Informatics which starts by pointing out that most health professionals do not use available health IT systems because they actually increase their work effort and can too frequently hurt quality, whereas the objective should be to help physicians decrease their work effort while increasing their quality consistently. They offer thoughts on a "physician-specific point-of-care system that continuously adapts to practice patterns that could result in dramatic improvements to the quality and efficiency of healthcare delivery".
General Healthcare Stories
• Process improvement to improve compliance with specialty visits
-- Turns out that when a PCP refers a patient to a specialist, they only make the appointment 70% of the time, and of those - only 70% show up - thus less than 50% of people go to the specialists when they are referred! This article talks about how a process improvement improved those metrics. Our medical group (www.NMPG.com) does something similar to help with this process and we believe it provides a higher quality and more efficient process for sure!
• Better ways to manage the flood of test results
-- New recommendations target how physicians and hospitals can best communicate test results and prevent harm to patients.
• Aftercare Tips for Patients Checking Out of the Hospital
-- NY Times article on how good discharge planning can keep patients from needing to be re-admitted after leaving a hospital, and could save Medicare billions.
• How the Performance of the U.S. Health Care System Compares Internationally (2010 Update)
-- Yet another report, placing the US healthcare system last among industrialized nations. US spends $7,300 per person per year on healthcare and gets the worst results. UK spends $3,000, New Zealand $2,500; Canada $3,900; Australia $3,400.
• Health overhaul may mean longer ER waits, crowding
-- Due to a shortage of primary care physicians (PCPs), Emergency Rooms may grow even more crowded with longer wait times under the nation's new health law since there will be many more patients with insurance, but no increase in PCPs.
• The Variability of Patient Care - by John Glaser
-- One of the smartest guys in healthcare explains the theory from one of my favorite books (Designing Care by Richard Bohmer),which I talked about in a previous post about Checklists and process improvement. The key point being that there are two classes of care in a hospital and in a physician's practice, and the importance of understanding that these two very diverse scenarios need to be recognized when designing process/workflows for care (especially including use of EHRs). Glaser explains further;
---- Sequential care is a form of production: It involves performing well-understood tasks in a well-understood sequence (e.g. routine heart surgery). Sequential care's mental image is that of a production line. With sequential care it is possible to engineer a preferred sequence of steps and have the EHR guide the care team in performing these steps. And it should be quite possible to measure the outcomes of these steps. (This is similar to Clay Christensen's Value Added Process)
---- Iterative care is a form of discovery: It addresses complex diagnoses and conditions for which the diagnosis and treatment are a repeating series of hypothesis-test/treat-revise hypothesis steps. Iterative care is different. The mental image should not be the factory floor but a group of scientists in the laboratory. In this scenario we must encourage collaboration, enable an unpredictable set of actions to be taken, and provide easy access to information and other experts that might help the team form and test hypotheses. Measuring the outcome of discovery is very difficult. (This is similar to Clay Christensen's Solution Shops)
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