Sunday, July 11, 2010

Usability and EMRs: An Update

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

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:
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.

• 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 (, 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.

* 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:
* 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:
* 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

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