usability and human factors - remote-learner user’s interactions in their normal workplace ... •...
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Usability and Human Factors
Electronic Health Records and Usability
Lecture c
This material (Comp15_Unit6c) was developed by Columbia University, funded by the Department of Health and Human
Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003.
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Electronic Health Records and Usability
Learning Objectives
2
• 1. Explain how user-centered design can enhance adoption of EHRs (Lecture c)
• 2. Discuss the role of usability testing, training and implementation of electronic health records (Lecture c)
• 3. Describe Web 2.0 and novel concepts in system design (Lecture c)
• 4. Identify potential methods of assessing and rating EHR usability when selecting an appropriate EHR system (HIMSS document) (Lecture c)
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Usability and Human Factors
EHRs and Usability
Lecture c
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Usability Challenges in Healthcare
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Usability and Human Factors
EHRs and Usability
Lecture c
Complex needs, time pressure
Vary from setting to setting, specialty
50 specialties; other professions• (OT, PT, pharmacists,
respiratory therapists etc.)
Team-based work
Clinician mobility, primary focus on patient (should
be)
Legal, ethical, errors, high-
stakes
Multiple standards,
evidence-based Medicine
Hard to get clinician feedback
Confidentiality makes in situ observation,
testing difficult
Cost of change (time, vendor,
consensus, cost)
Interruptions, time pressure,
institution policies
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More issues
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EHRs and Usability
Lecture c
• Clauses mean institution liable
Hold harmless
• Clinician responsible even if no choice or access to guts of software
Learned intermediary
• 25% medication errors (2006) involved computer technology
• 82% of these CPOE/data entry
Patient Safety
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Basic Minimums
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Usability and Human Factors
EHRs and Usability
Lecture c
Usability = Efficiency of use + usefulness + ease of use?
For EHRs, we want to:
• Minimize likelihood of user error
• Provide cognitive support – guide interaction to foster good work, no errors
Avoid:
• Errors of commission: e.g. wrong patient chart
• Errors of omission: e.g. fail to notice abnormal result
• Failure to complete task (due to interruption and no handling of interruption)
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Evidence-based Usability/Cognitive Support
6Health IT Workforce Curriculum
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EHRs and Usability
Lecture c
• Usability is not just screen or software
design
– Affected by workflow, time pressure, physical
space layout, lighting, policies for use, and
even user experience during implementation
• Design needs to be evidence based, and
evidence is available» Karsh, 2010
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Evidence-based Usability/Cognitive Support (cont.)
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Lecture c
Fact:
• Healthcare is complex, training will be required
Myths:
• No training needed with good usability
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Evidence-based Usability/Cognitive Support (cont.)
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Fact:
• Users not trained in science of usability and cognition
• What they want may be wrong, mis-specified, or inarticulate
Myth:
• User-centered design = give users what they want
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Evidence-based Usability/Cognitive Support (cont.)
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Myth:
• Health IT should integrate into workflow
Fact:
• Healthcare workflow is emergent
• what is needed is more flexible availability of data
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Evidence-based Usability/Cognitive Support (cont.)
• Usability is not a fixed target
• Don’t think we have the answers
• Ongoing research is needed» Karsh, 2010
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Evidence-based Design Exists: AHRQ Resources
Electronic Health Record Usability:
– Interface Design Considerations Recommended actions to support development
of an objective EHR usability evidence base, formative policies
– Evaluation and Use Case Framework literature and best practices regarding the
usability of EHRs, use cases for primary care IT evaluation
– Vendor Practices and Perspectives: current usability processes, practices, and
perspectives of certified EHR vendors
•Available at: http://healthit.ahrq.gov
Redish, et al., (2010).
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Usability Testing
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“In routine handling, the Sorrento feels responsive
in corners, with nicely weighted, quick steering… The gated zigzag shifter is
awkward to use”
“It posted a commendable speed through our
avoidance maneuver. Avoidance maneuver,
max. spd: 51.5 mph. 0 to 60 mph: 7.6 sec”
Two Voices in Consumer Reports Car Reviews
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Subjective v. Objective
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Subjectivist/Qualitative (“art criticism”)
• Not everything of importance can be quantified
• Differences of opinion are okay
• The value is in the “thick description”
• Rigorous methods exist (one is formal criticism)
Objectivist/Quantitative
• Believable knowledge derives from measurement of attributes that are inherent in objects
• All observers should agree on measurement results (inter-subjectivity)
• On what result is “better” (polarity)
• Accuracy
• Response time
• Time to identify / Time spent searching
• Eye gaze
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Heuristic Evaluation
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Expert(s) evaluate system according to heuristics (Norman)
• 1. Visibility of system status
• 2. Match between system and the real world
• 3. User control and freedom
• 4. Consistency and standards
• 5. Error prevention
• 6. Recognition rather than recall
• 7. Flexibility and efficiency of use
• 8. Aesthetic and minimalist design
• 9. Help users recognize, diagnose, and recover from errors
• 10. Help and documentation
10 main axes:
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Focus Groups
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• Find out information designers can use
• What should the system do?
• What are users worst problems?
• What is their workflow?
• How do they do the task now?
Use for formative evaluation
Use for summative evaluation (after system is built)
• Group similar users together
• Don’t put supervisors with staff (people should feel free to speak)
Method: get typical users to view and discuss system and related ideas
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Focus Groups (cont.)
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Prepare open-ended questions, not yes/no
Provide fixed time, food
• Clinicians are busy and highly paid
• Compensate appropriately, e.g. $100/hour
Compensate users
• Institutional Review Board
Get permission in writing
• e.g. participants will be anonymous in any publications, talks
Define privacy policy
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Focus Groups (cont.)
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Record meeting (two digital or tape recorders); obtain permission of subjects
Transcribe and code thematically
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Usability TestingThink aloud, in-lab
• Subject (typical user) uses system in quiet office, software captures video of their screen actions and voice (and face, if desired)
• User is told to think aloud while using software for typical tasks
• Video is coded and analyzed for themes, action patterns, problems, time for tasks…
• Morae software is a common tool– http://www.morae.com
– Requires webcam with sound, can do remote testing
• Video can be edited for administrators, clients, decision-makers, programmers
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Field Usability Testing
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Examine user’s interactions in their normal workplace setting
• Important method to establish conditions of work, workflow
Field observation
• What are time constraints, interruptions, noise, information sharing with colleagues, information flow, information sources, needs, team members?
Answer questions such as
• Morae testing will be the main methods
Observation, log file analysis, user interviews, and perhaps remote
Problems not detected in a laboratory test likely to come to light after deployment
Monitor usage closely soon after deployment
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Cognitive Walkthrough
• Method of inspecting software for
problems
• Have goal, sub-goal, actions taken,
system response, potential problems
• Classify problems:
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1. Cosmetic
• Need not be fixed unless time available
2. Minor usability
• Low priority for fix
3. Major usability
• High priority
4. Usability catastrophe
• Imperative to fix
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Scenes from a Walkthrough
Senathirajah & Bakken, (2008).
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Context: Patient Presents with a medical problem to a Family Physician’sOffice
Task: Diagnostic Reasoning
Goal Structure and Action SequenceGoal: Represent chief complaintChief Complaint: Patient complains that she has been feeling pretty tired
for the past 6 months
Subgoal 1: Characterize Patient’s Observation of TirednessAction 1: Open Top-Level Category General ConditionSystem Response: Displays Findings Organized by CategoryPotential Problem: System has sluggish response
Subgoal 2: Enter Finding FatigueSubgoal 3: Locate FindingAction 2: Open Category/Select Finding "Fatigue"
Subgoal 4: Describe Severity/QualitySubgoal 5: Translate quality "Pretty Tired" into Quantity indicating
SeverityAction 3: Enter severity: Three +++Action 4: Selects Quality: Lack of energy
Subgoal 6: Indicate ChronologyAction 5: Selects chronology duration of 6 monthsSystem Response: Displays chronology in "years“Potential Problem: “years” is not appropriate unit for 6 months
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The Special Case of CPOE
• Poor CPOE design can facilitate medical
error
– e.g. overdose, wrong patient given drug
• Quantitative and qualitative studies show
flaws leading to errors
• Many adverse drug events due to poor
interface
• Heavy cognitive demands22
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Koppel:EHR Interface flaws
• Can’t clearly identify the patient
• Can’t view all meds on single screen
• Log-in/log-out failures
• Extra steps required to ‘activate’ orders
• Automatic cancellation of pre-surgical orders
• Downtime delays
• Orders near midnight interpreted as ‘tomorrow’
• Cumbersome interface – charting difficult
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CPOE-related Usability Problems
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• Deep navigational structures requiring multiple clicks
• Too close screen elements -> errors in selections
• Same color for data entry fields and others
• Long drop-down menus requiring scrolling
• Documentation templates different from clinician cognitive model of ordering
• Use of string sensitive data fields for abbreviations
• Excessive alerts, alerts which do not appear at appropriate time (when clinician would look for that information)
• Excess screen density, or too many screens
• Obscure hierarchies of orders or order sets
Avoid:
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CPOE Design Recommendations
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View complete medication record on one screen, avoid scrolling/other screens/fragmentation
Avoid subtle differences in layout, forms, labels for large functional differences
Explicit time indications
Map interface to ordering workflow
Maximum 3 layers of screens
Use consistent terms, organize elements into logical groups, separated by space, alignment
Distinguish active and passive elements
Consistent, sparing color
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Technology Effects
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• How performance changes when one uses a system
Effects with technology
• Longer-term effects of technology on cognition, even when the technology is no longer being used
Effects of technology
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Information Gathering Strategies
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• Requests for information guided by clinician’s hypothesis independent of the screen displays
Hypothesis-driven strategy:
• Guided by the ordered sequence of information on the computer screenScreen-driven:
• Novice changed from hypothesis-driven strategies to screen-driven
With experience:
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Study Results
• Paper-based records– Narrative form, with connected and linked text and
sentences
• EMRs– More info on patient’s past medical history, lifestyle, and
primary diagnosis
– Information entered in point form, not linked in narrative
– Followed structure and sequence of system
– Time course not adequately captured
• Post EMR paper-based record– Closely resembled EMR in structure and format
– No connecting narrative
– Limited info on time course
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Web 2.0 and Modern Approaches
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• Give the user more control
‘Web 2.0’ is a change in internet approaches
Both philosophical approaches & technical approaches
• e.g. Facebook
Social networking applications
• Obtain information or judgment from a large group of users
Crowd sourcing:
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Web 2.0 and EHRs
• Facilitate user control, a better user
experience, new forms of interactive
information display, and social networking
• Address problems of clinician
collaboration, optimal design of EHRs,
flexibility to meet rapid change, and other
problems
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Electronic Health Records and Usability Summary
• EHR usability is a complex area in which we do not yet
have standards, but best practices are being intensively
studied
• Usability is one of the most important factors affecting
adoption, satisfaction, and optimal use of EHRs
• Usability should be an important factor in selection and
deployment of a system
• In the next two years much research will be done in this
area; it is important to keep abreast of developments
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Electronic Health Records and Usability
References – Lecture cReferences
1. Karsh, B.TB. (2010). Health IT Design and Usability: Myths and Realities. AHRQ/NIST EHR Usability Conference;
2010; Washington DC.
2. Koppel , R., Metlay, J.P., Cohen, A., Abaluck, B., et al. (2005). Role of computerized physician order entry
systems in facilitating medical errors. JAMA 293(10): 1197-1203.
3. Patel V, Kushniruk A. Cognitive and usability engineering methods for the evaluation of clinical information
systems. Journal of Biomedical Informatics. 2004;37(1):56-76.
4. Patel VL, Kushniruk, A.W., Yang, S., & Yale, J.F. . Impact of a computerized patient record system on medical data
collection, organization and reasoning. J of the American Medical Informatics Association. 2000;7(6):569-85.
5. Shabot M. Ten commandments for implementing clinical information systems. Proc (Bayl Univ Med Cent).
2004;17(3):265-9.
6. Staggers N, Mills ME. Nurse-Computer Interaction: Staff Performance Outcomes. Nursing Research.
1994;43(3):144-50.
7. Zhu X, Gold SA, Lai A, Hripcsak G, Cimino J, editors. Using Timeline Displays to Improve Medication
Reconciliation. 2009 International Conference on eHealth, Telemedicine, and Social Medicine; 2009.
8. Belden J. EHR usability: an illustrated guide. AHRQ/NIST EHR Usability Conference; 2010; Washington DC:
National Institute of Standards and Technology.
9. Friedman, C. (2010). Usability in Health IT: technical strategy, research, and implementation: summary workshop.
National Institute of Standards and Technology, U.S., Department of Commerce. Retrieved on September 4th,
2012 from http://www.nist.gov/itl/hit/upload/U-HIT_Workshop_Report_Publication_Version.pdf
10. Khajouei, R., Jaspers, MWM. CPOE System Design Aspects and Their Qualitative Effect on Usability. eHealth
Beyond the Horizon.
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Electronic Health Records and Usability
References – Lecture cImages
Slide 11: Redish, J.G., Lowry, S.Z., Locke, G., Gallagher, P.D., Friedman, C. (2010). Usability in Health IT: technical
strategy, research, and implementation: summary workshop. National Institute of Standards and Technology, U.S.,
Department of Commerce. Retrieved on September 4th, 2012 from http://www.nist.gov/itl/hit/upload/U-
HIT_Workshop_Report_Publication_Version.pdf
Slide 21: Senathirajah Y, Bakken, S., editor. A User-Configurable EHR using Web 2.0 Approaches. AMIA Spring 2008;
2008; Phoenix, AZ: AMIA.
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