What if US healthcare providers dramatically adopted EMRs in increasing numbers, worked hard to achieve meaningful use, but never benefited financially or in efficiency or quality? Meaningful use will be dependent on adequate EMR usability. Discover how usability relates to a number of meaningful use criteria. We offer a usability checklist to assist providers in shopping for a new EMR, or to use during implementation of an existing EMR, in order to achieve efficiency, effectiveness, and usefulness. Presentation to HIMSS 2010 with co-presenter Janey Barnes PhD.

1. ARRA and
EMR Usability
What Providers Need to Know

2. Conflict of Interest Disclosure
Jeff Belden MD
Dr. Belden is on the faculty at University of Missouri
- Columbia, which has a contractual consulting
relationship with Cerner for EMR research and
development.
Dr. Belden has no financial interest.

3. Conflict of Interest Disclosure
Janey Barnes PhD
Contracted Research:
• Allscripts,
• Patagonia Health,
• Duke Health Systems

4. Low EMR Adoption Rates

5. EMR Adoption Hospitals - 2008
100%
Full Basi Basic without None
c clinician notes
AK Jha et al, NEJM 2009

6. EMR Adoption Doctor Offices – 2007-08
100%
Full Basic None
CM DesRoches et al, NEJM 2008

7. Why?

8. Barriers
• Purchase price
• Uncertain ROI
• Lost productivity
• Finding an EMR that meets
needs
• Obsolescence concerns

9. Usability missing
Smelcer 2009

10. What is ^usability?

11. Usability is
Effectiveness
Efficiency
Satisfaction
ISO 2003

12. Usability means
Learnable
Efficient
Memorable
Error-free
Satisfying
Useit.com

13. Current EMRs
lack good usability
Smelcer 2009

14. examples

15. Time consuming
dictation takes 33 seconds
EMR can take 10x longer

16. Alert Fatigue
of high-priority DDI alerts…
90% ignored

17. Complex steps
hard to learn
Longer, costly training

18. AAFP EMR Survey 2009
User satisfaction ratings
from 2,012 Family Physicians

21. Usability is…

22. 10 Principles
1. Simplicity 7. Feedback
2. Naturalness 8. Effective use of
3. Consistency language
4. Minimizing cognitive 9. Effective information
load presentation
5. Efficient interactions 10.Preservation of
6. Forgiveness context
http://bit.ly/UsabilityHIMSS

23. Simplicity

24. Simplicity
For doing refills
For overview only

25. Naturalness

26. Naturalness
Old way – lots of drill-down clicking

27. Naturalness
Better way
we know the body
already

28. Consistency

29. Consistency
Name and identifying info consistently placed

30. Minimizing Cognitive Load

31. Minimizing Cognitive Load
Exact past dates
• This requires mental math

32. Minimizing Cognitive Load
Relative past dates
• Easier. No extra thinking.

33. Minimizing Cognitive Load
Hover to see more detail
• Have it both ways

34. Efficient Interactions

35. Efficient Interactions
Dashboard efficiency

36. Efficient Interactions
50 Clicks…
• 6 minutes

37. Efficient Interactions
2 Clicks…
• 1-2 minutes

38. Efficient Interactions
Dashboard benefits
• Single visual plane
• No navigation away needed
• No need to recall last screen’s content
• Use hover-over, or pop-up windoids

39. Efficient Interactions
Dashboard principle
Show me
WINWINIANM
(what I need, when I need it, and nothing more)

40. Forgiveness

41. Forgiveness
Let users discover by
exploring without fear of destroying
Let users recover gracefully
from mistakes

42. Forgiveness
A bad example…

43. Feedback

44. Feedback
• Don’t keep the user wondering
• Show expected delays
• Confirm changes that aren’t evident

45. Feedback
Imagine this scenario
• Imagine a user clicks a page element,
and a long, slow database call
ensues…

46. Acceptable

47. Better
Please wait while we
check 10,357
records…

48. Best
Time remaining… 8 seconds
Please wait while we
check 10,357
records…

49. Effective Use of Language

50. Terse for doctor
Plain English for patient

51. Effective Information Presentation

52. Effective Information Presentation
Sorted alphabetically, not randomly
Better yet, allow sort by other criteria, t

53. Preservation of Context

54. Preservation of Context

55. ARRA’s
Meaningful Use Matrix
Where does usability fit in?

56. Meaningful Use (MU)
5 Health Outcome Policy Priorities
1. Improve quality, safety, efficiency, &
reduce health disparities
2. Engage patients & families
3. Improve care coordination
4. Improve population & public health
5. Ensure adequate privacy & security
protections for personal health information

57. Meaningful Use (MU)
We picked 3
1. Improve quality, safety, efficiency, &
reduce health disparities
2. Engage patients & families
3. Improve care coordination
4. Improve population & public health
5. Ensure privacy & security protections for
personal health information

58. MU > Improve Quality
1. Improve Quality…
1. Evidence-based CPOE
2. Clinical decision support at the Point-of-
care
3. Registries for patient outreach

59. MU > Quality > EBM CPOE
Evidence-based CPOE
…building ruts to quality & safety
examples…

60. MU > Quality > EBM CPOE
Antibiotic Selection for
Community-Acquired Pneumonia
Usability principles
1. Simplicity
2. Efficient interactions
3. Minimizing cognitive load

61. MU > Quality > EBM CPOE

62. MU > Quality > EBM CPOE > Simplicity
Simplicity

63. MU > Quality > EBM CPOE > Min cognitive load
Minimize cognitive load

64. MU > Quality > EBM CPOE > Efficient
Efficient interactions

65. MU > Quality > CDS at POC
Clinical Decision Support
at the Point of Care
examples…

66. MU > Quality > CDS at POC > Problem List
Problem Lists
Usability principles
1. Simplicity
2. Naturalness
3. Effective use of language
4. Effective information presentation

67. MU > Quality > CDS at POC > Problem List > Simplicity
Simplicity

68. MU > Quality > CDS at POC > Problem List > Simplicity
The old way...

69. MU > Quality > CDS at POC > Problem List > Simplicity
Better way

70. MU > Quality > CDS at POC > Problem List > Naturalness
Naturalness
Sort & sequence like clinicians think
Not by diagnosis code.. … but alphabetically

71. MU > Quality > CDS at POC > Problem List > Naturalness
Effective use of language
Common ways you could display Diabetes 250.00 (ICD-9)
Just use words physicians use
What would Dr. Jesus say?

72. MU > Quality > CDS at POC > Problem List > Info Prez
Effective Info Presentation
Sorted alphabetically Sorted for cardiology

73. MU > Quality > CDS at POC > Problem List > Info Prez
Effective Info Presentation
Highlighted for cardiology Filtered for cardiology

74. MU > Quality > CDS at POC > Alerts
Alerts
Usability principles
1. Simplicity
2. Efficiency
3. Effective information presentation

75. MU > Quality > CDS at POC > Alerts > Simplicity
Too busy visually…

76. MU > Quality > CDS at POC > Alerts > Simplicity
Try to find the essence…

77. MU > Quality > CDS at POC > Alerts > Simplicity
All the doctor needs to see

78. MU > Quality > CDS at POC > Alerts > Simplicity
Simplicity

79. MU > Quality > CDS at POC > Alerts > Info Presentation
Effective info presentation
Show only what the physician
wants
• Severity
• What is the adverse effect?
• Alternative actions

80. MU > Quality > CDS at POC > Alerts > Feedback
Efficient interactions
• Prevent repeated alerts for same
combo
• Prevent alerts for low-level danger
• Let user adjust alert level

81. MU > Quality > CDS at POC > Lab
Lab results
Usability principles
1. Effective information presentation
2. Minimize cognitive load
3. Preservation of context

82. MU > Quality > CDS at POC > Lab > Info Presentation
Effective info presentation
old
new

83. MU > Quality > CDS at POC > Lab > Min cognitive load
Minimize cognitive load

84. MU > Quality > CDS at POC > Lab > Preserve context
Preservation of context
Compare to prior lab, two year graphical trend

85. MU > Quality > CDS at POC > Lab > Preserve context
And what medication is he/she on?
And what is the weight and BP doing?

86. MU > Quality > Registries
Registries
examples…

87. MU > Quality > CDS at POC > Problem List
Quality Registry: Dashboard
Usability principles
1. Efficient interactions
2. Effective information presentation

88. MU > Quality > Registries > Quality dashboard
Diabetes quality dashboard

89. MU > Quality > Registries > Quality dashboard
Efficient interactions
Give actionable info at Point-of-Care

90. MU > Engaging Patients > Access to health record
Engaging Patients
Giving e-access to health records
examples…

91. MU > Engage patients
Clinical Summary
Usability principles
1. Effective use of language
2. Efficient interactions

92. MU > Engage patients > Clinical summary
Clinical Summary at Visit
A take-home for
the patient

93. MU > Engage patients > Clinical summary

94. MU > Engage patients > Clinical summary
Effective Language
Plain English

95. MU > Engage patients > Clinical summary
Efficient
And
something
for the
wallet

96. MU > Engage patients > View lab on web
Viewing lab results on web
Usability principles
1. Effective use of language
2. Effective information presentation

97. MU > Engage patients > View lab on web
Viewing lab results on web

98. MU > Engage patients > View lab on web
Effective Language
Change ”Reference” to ”Normal Range”

99. MU > Engage patients > View lab on web
Effective info presentation
What would patient expect to find?
•Highlight unviewed results
•Abnormal in color
•Doctor’s annotations to explain

100. MU > Engage patients > View lab on web
Effective Info Presentation
Easy to misunderstand “which normal range”

101. MU > Engage patients > e-Copy
Web Access or e-Copy
Usability principles
1. Naturalness
2. Forgiveness

102. MU > Engage patients > e-Copy
Naturalness

103. MU > Engage patients > e-Copy
Forgiveness

104. EMR Buyer’s Guide
Shopping for usability
Before you buy, or implement…

105. MU > Before you buy
It’s a process…
Define what’s Important to You
• Evaluate your alternatives
• Select the alternative that is best for your
team

106. MU > Before you buy
What’s important to you
Effectiveness
•What do you want /need from your EMR?
•How will this product meet those wants / needs?
•See barriers when you try the product?

107. MU > Before you buy
What’s important to you
Efficiency
•What outcomes should be better
• Faster
• more robust
• have better payoff

108. MU > Before you buy
What’s important to you
Satisfaction
•Of which users?
•For which key tasks?
•In which clinical setting or environment?

109. MU > Before you buy
Evaluate Your Alternatives
What do your friends say
• Ask, ask, ask!
• Go watch your friends at work on their EMR
• with their actual patients.
• not a demo in the office.
• watch others while you are there.

110. MU > Before you buy
Evaluate Your Alternatives
What do your colleagues say
• Blogs, etc.
What do your professional groups & others say
• KLAS
• AAFP
• Your state’s academy of …

111. MU > Before you buy
Evaluate Your Alternatives
What do you and your team say
• Do your own evaluation
• Create 3-5 primary care clinical scenarios
• Time critical tasks in those scenarios
• Set targets that you want
• A few users rate qualitative aspects of the
software with 5-point scale
• Evaluate reporting functions

112. MU > Before you buy
Creating Clinical Scenarios
1.Choose ones that matter
• frequent, important
• Include prescribing
• Include “hey-doc” request
2.Test them
3.Look for efficiencies
• e.g. document normal ROS with one click

113. MU > Before you buy
Buyer Beware
Try Out the Reporting Function
• What will you want to report?
• A1Cs in diabetics
• BP control rates in hypertension
• List of patients on a particular recalled drug
• Should be easy
• Look for efficiencies
• Out of the box experience
• Easy to make reports quickly

114. MU > Before you buy
Buyer Beware
Don’t be “wowed” by Templates
Don’t be impressed with installed templates
• Try them out first
• Try to make one yourself (with no training)
Don’t expect clinicians to create or edit
• Try to make some
• Ideal: Easy to make on the fly.
• Even a caveman (a physician) can do it!

115. MU > Before you buy
Buyer Beware
Training
• Touch on initial training
• you & staff will be overwhelmed at launch
• Demand later training
• after you have the basics down

117. Want to learn more?
• EMR Usability Principles and
Proposed Testing
• http://bit.ly/UsabilityHIMSS
• Checklist - Evaluating Usability in an
EMR before you buy
• http://bit.ly/shopEMR

118. ARRA & Usability: What Providers Need to Know
Questions?
Janey Barnes PhD | jbarnes@user-view.com
Jeff Belden MD | beldenj@health.missouri.edu

119. Want to learn more?
• EMR Usability Principles and
Proposed Testing
• http://bit.ly/UsabilityHIMSS
• Checklist - Evaluating Usability in an
EMR before you buy
• http://bit.ly/shopEMR
Janey Barnes PhD | jbarnes@user-view.com
Jeff Belden MD | beldenj@health.missouri.edu