White Paper
Cybage Electronic Medical Record (EMR) Usability
Introduction
In the Electronic Medical Record (EMR) product space, usability is often ignored as the focus is on regulatory compliance, standard certifications, and enterprise interoperability of a product. Usability affects almost the entire care-delivery lifecycle of an EMR product. Some of the impacts such as decline in clinical error rate and clinical documentation compliance rate are tangible and can be measured.
In this paper, we shall discuss ways to apply the established usability principles and thereby improve the usability of the EMR applications. However, before we discuss these principles, we will touch upon the goals we intend to achieve by improving the overall usability of the EMR applications. We will also discuss concrete example(s) for implementation of a usability principle.
Table of Contents
01 1. Introduction
02 1.1 Usability Goals In EMR 03 1.2 Usability Principles In Action
03 1.2.1 Information Architecture
04 1.2.2 Interaction Design
05 1.2.3 Visual Design
07 1.3 Usability Grid
1.1 USABILITY GOALS IN EMR From an end user perspective, the
following can be the goals of any usability- enhancement exercise:
• To prevent clinical errors
• To improve staff productivity
• To improve user satisfaction and thereby the adoption rate
These goals are often interlinked and hence are difficult to achieve in isolation. For example, if an EMR product does not allow a provider to be productive, it immensely reduces the probability of the provider completely embracing the Electronic Health Record (EHR) product. Following is a brief explanation of the goals mentioned earlier:
• To prevent or reduce clinical errors Clinical errors can occur due to multiple reasons and at any stage of the care- delivery process. Some of the reasons for such errors are unavailability of information, information not captured properly, or absence of appropriate checks and balances. Apart from the fact that these errors can lead to potentially costly and complicated consequences, they set back the primary goal of a feature-rich EMR that helps providers deliver quality care. Hence it would be prudent to say that preventing or even reducing clinical errors should be the topmost goal of any usability- enhancement exercise.
• To improve productivity
Doctors are a harried lot. Hundreds of patients rush to them every day for medical assistance. Each decision that a doctor takes calls for subsequent actions that in turn require multiple data points or information types. Complexity in accessing relevant information or in carrying out required actions reduces the productivity of the providers and increases the overall frustration. The problem becomes more complicated for the staff responsible for medical documentation. Hence it is imperative that all stakeholders in a care-delivery cycle execute their job with optimal efficiency in any usability-enhancement exercise.
• To improve adoption and satisfaction All usability principles ultimately
strive to improve user acceptance and satisfaction; that is what users feel after using the application. Needless to say that if providers or staff perceive their experience with a given EMR product to be good, it greatly increases the probability that they will adopt it and use all its features effectively. This usability goal is important for software vendors selling EMRs because if a product has good user feedback, chances are that it will sell more!
1.2 USABILITY PRINCIPLES IN ACTION In this paper, we shall discuss the usability principles that we intend to leverage upon to achieve the aforementioned goals. The usability principles can be categorized along multiple axes, here the classification and grouping is done based on how the users interact with an application.
1.2.1 INFORMATION ARCHITECTURE To carry out any action, providers need access to varied information at various levels of granularity. These could include medication history, patient’s vital
information, social background, and immunization history, among others.
The efficiency with which providers can consume and assimilate this information largely depends on how this information is organized and presented to them. In the current section, we will discuss some of the related nuances, which can be referred to as information architecture of the referred EMR application. These are:
• Availability of relevant information Relevance of information is the key and probably this is what makes the implementation of this particular usability principle challenging. Primary function of every screen in an EMR is to help users perform a particular clinical action or decision. As a thumb rule, only information required to perform given clinical action should be present on the given screen. Irrelevant information
history, medication history, and disease history should be made available.
• Relevant information grouping This is a corollary to the previously discussed principle of availability of information. Care delivery is an
information-intensive process. Presenting all relevant information on a single screen can be challenging. Hence it is imperative that all relevant clinical information be grouped appropriately based on its type and presented at the right granularity.
There are two primary aims of this exercise—to help the users organize available information for easy access, and provide the information with the adequate level of detail so that the providers can make sense out of the information without getting overwhelmed by it.
For example, while displaying medication history on a drug prescription screen, the name of the drug and the current usage status can be the first level of detail while dosage, drug label information, dispense
• Effective visual representation To make clinical decisions, providers
have to interpret clinical data. Visual representations of such textual clinical information prove to be a useful aid for comprehension and interpretation.
Color coding can be used as an alert for probable allergies or to convey status of patients’ vitals or lab reports.
Similarly, trending graphs can be used to comprehensively track status of a vital parameter over a given period of time.
1.2.2 INTERACTION DESIGN
After the initial cognition of the EMR application screen and information assimilation, the next logical step for a provider or staff member is to use the application during the care- delivery process. What affects the user experience here is the intuitiveness of the implemented workflows in the application and the ability of these workflows to help prevent clinical workflows, among others.
In this section, we shall discuss these aspects of the user experience. Parameters such as responsiveness and reliability of the EMR application, while delivering patient care, are of critical importance in the usability experience of an EMR application, but are beyond the purview of this white paper.
• Intuitiveness
Providers will find an EMR application user-friendly if the workflows
implemented, closely mimic the existing workflows implemented in the practice.
This greatly reduces the learning curve and thereby increases the probability that the provider will be able to use the EMR application effectively. This is also
referred to as intuitiveness of an EMR application. The challenge in the clinical world is that there can never be a one- size-fits-all approach. For example, workflows of an obstetrics practice will be drastically different from that of an orthopedic practice. To achieve this goal, the EMR vendors have to enable creation of customizable workflows and templates to capture clinical data. Given the
complexities involved, EMR vendors often fall short of this goal. This is why we have specialty-specific EMR implementations.
• Error feedback
Clinical errors can prove costly and defeat the goal of helping providers deliver quality patient care by using a feature-rich EMR. The EMR should warn a provider about any potential clinical or compliance error before the provider commits it. The idea is to force the provider to read the relevant warning message and rethink the decision or course of action. It is akin to asking “Are you sure you want to do this”? Or “Have you done this”? Ideally a provider or staff should not be allowed to continue using the given care-delivery workflow till the relevant warning question is answered.
An example here can be a check for drug-drug or drug-disease allergies or interaction checks during the drug prescription process. Another example can be a check for the absence of recommended diagnosis test for a given illness. For giving out a warning, a warning question or alert pops up. The provider has to answer this question before being allowed to move ahead. The provider can also be reminded about HIPAA compliance disclosure agreements while sharing Protected Health Information (PHI). The intelligence for these warnings should be implemented in the clinical decision management component of the EMR or implemented as a part of configurable checklists or workflow tweaks.
• Forgiveness
This is in continuation of or a corollary to the usability principle discussed previously.
It, however, has a larger scope. While there will be system identified clerical or clinical errors during care-delivery process, it is imperative that the EMR application does not penalize a provider or staff for committing these errors by increasing their workload. For example, if a provider has mistakenly selected a drug that has an adverse interaction in a given allergic condition, the EMR application should not force the provider to resubmit the entire encounter data. The provider should be allowed to change the drug and continue with the care-delivery workflow.
the number of steps (and time) required to execute a given clerical or care delivery workflow. This interaction efficiency depends on a number of usability principles discussed so far, namely availability or grouping of information and naturalness of workflows, among others. It can also be influenced by simple user interface decisions such as layout of screen, amount of scrolling required to access a given part of screen, and use of auto tabbing for desktop-based applications, among others. It is also influenced by functional decisions such as availability of auto-complete feature while searching for a given item in a long list.
For example, instead of making providers use an extensive dropdown list, an autocomplete feature can allow the providers to search for a given drug.
1.2.3 VISUAL DESIGN
Before a provider or staff starts using an EMR application, what happens is the subconscious cognizance of what the given EMR screen has to offer. In broader terms, this can be referred to as the general look-and-feel of the application.
Apart from the fact that perception or the mood of the users is set by this process of subconscious cognizance, what is also determined here is the next most probable course of action by users. Hence the goal of all usability principles related to visual design is to aid the process of cognition and to make the experience pleasant. These are:
• Readability
Providers often need to read clinical information that includes referral reports and detailed drug reference reports, among others. Hence it is important for providers to scan and comprehend this clinical information quickly. Simplicity, intuitiveness, use of comprehensive language, density, and color; all contribute to readability. Use of appropriate font size can help in attaining better efficiency and in error prevention. Users should be able to adjust the font size according to their preference. Other measures include use of standard fonts and appropriate contrast between text and background.
simple, organized, and without too much clutter. This can be achieved either by reorganizing available information, eliminating the irrelevant information, or making it available on demand. The principle of simplicity can be applied to other usability aspects such as information organization and user interaction.
• Consistency
After providers or staff members start using a given EMR, they subconsciously derive a pattern about expected
application behavior. For example, if a window of a desktop-based application is closed by the ‘Esc’ key, providers or staff members will expect all windows of the application to behave accordingly.
However, if behavior in a given flow or screen of the application belies this set expectation, it may frustrate them and also may lead to inadvertent error.
Improve
productivity Reduce error
rate Improve user
satisfaction
Visual design
Simplicity √ √
Consistency √
Information architecture
Grouping or availability of relevant information √ √
Readability √ √
Meaningful use of color √ √
Interaction design
Naturalness √ √ √
Forgiveness or feedback √ √
Effective interactions √ √ √
1.3 USABILITY GRID
All usability principles discussed in this article help to achieve the usability goals that we had outlined earlier; to reduce error rate, to improve productivity, user satisfaction, and adoption rate. However, it can be argued that there are situations where a particular goal in the list may be more prominent than the others. The following grid is an attempt to summarize this more prominent applicability of a usability principle vis-à-vis the given goal.
Cybage Software Pvt. Ltd.
