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ARRA and
EMR UsabilityWhat Providers Need to Know
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.
Contracted Research: • Allscripts, • Patagonia Health, • Duke Health Systems
Conflict of Interest Disclosure
Janey Barnes PhD
Crisis
Really big concern
Low EMR Adoption Rates
Full Basic None
EMR Adoption Hospitals - 2008
100%
AK Jha et al, NEJM 2009
Basic withoutclinician notes
Full Basic
EMR Adoption Doctor Offices – 2007-08
100%
CM DesRoches et al, NEJM 2008
None
Why?
Barriers•Purchase price•Uncertain ROI•Lost productivity•Finding an EMR that meets needs•Obsolescence concerns
Usability missing
Smelcer 2009
What is usability?EMR
^
Usability isEffectivenessEfficiencySatisfaction
ISO 2003
Usability meansLearnableEfficientMemorableError-freeSatisfying
Useit.com
Current EMRs lack good usability
Smelcer 2009
examples
Time consumingdictation takes 33 seconds
EMR can take 10x longer
Alert Fatigueof high-priority DDI alerts…
90% ignored
Complex stepshard to learn
Longer, costly training
AAFP EMR Survey 2009User satisfaction ratingsfrom 2,012 Family Physicians
Usability is…
10 Principles1. Simplicity2. Naturalness3. Consistency4. Minimizing cognitive
load5. Efficient interactions6. Forgiveness
http://bit.ly/UsabilityHIMSS
7. Feedback8. Effective use of
language9. Effective information
presentation10.Preservation of
context
Simplicity
For doing refills
For overview only
Simplicity
Naturalness
Naturalness
Old way – lots of drill-down clicking
Naturalness
Better way we know the body already
Consistency
Consistency
Name and identifying info consistently placed
Minimizing Cognitive Load
Minimizing Cognitive Load
Exact past dates• This requires mental math
Minimizing Cognitive Load
Relative past dates• Easier. No extra thinking.
Minimizing Cognitive Load
Hover to see more detail• Have it both ways
Efficient Interactions
Dashboard efficiencyEfficient Interactions
Efficient Interactions
50 Clicks…• 6 minutes
Efficient Interactions
2 Clicks…• 1-2 minutes
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
Efficient Interactions
Dashboard principle
Show me WINWINIANM
(what I need, when I need it, and nothing more)
Forgiveness
Forgiveness
Let users discover by exploring without fear of destroying
Let users recover gracefully from mistakes
Forgiveness
A bad example…
Feedback
Feedback
• Don’t keep the user wondering• Show expected delays• Confirm changes that aren’t evident
Feedback
• Imagine a user clicks a page element, and a long, slow database call ensues…
Imagine this scenario
Acceptable
Better
Please wait while we check 10,357 records…
Best
Please wait while we check 10,357 records…
Time remaining… 8 seconds
Effective Use of Language
Plain English for patient
Terse for doctor
Effective Information Presentation
Effective Information PresentationSorted alphabetically, not randomly
Better yet, allow sort by other criteria, too
Preservation of Context
Preservation of Context
Meaningful Use MatrixARRA’s
Where does usability fit in?
5 Health Outcome Policy Priorities
1. Improve quality, safety, efficiency, & reduce health disparities
2. Engage patients & families3. Improve care coordination4. Improve population & public health5. Ensure adequate privacy & security
protections for personal health information
Meaningful Use (MU)
We picked 3
1. Improve quality, safety, efficiency, & reduce health disparities
2. Engage patients & families3. Improve care coordination4. Improve population & public health5. Ensure privacy & security protections for
personal health information
Meaningful Use (MU)
1. Improve Quality…
1. Evidence-based CPOE2. Clinical decision support at the Point-of-care3. Registries for patient outreach
MU > Improve Quality
Evidence-based CPOE…building ruts to quality & safety
examples…
MU > Quality > EBM CPOE
Antibiotic Selection forCommunity-Acquired Pneumonia
Usability principles1. Simplicity2. Efficient interactions3. Minimizing cognitive load
MU > Quality > EBM CPOE
MU > Quality > EBM CPOE
MU > Quality > EBM CPOE > Simplicity
Simplicity
MU > Quality > EBM CPOE > Min cognitive load
Minimize cognitive load
MU > Quality > EBM CPOE > Efficient
Efficient interactions
Clinical Decision Support at the Point of Care
examples…
MU > Quality > CDS at POC
Problem Lists
Usability principles1. Simplicity2. Naturalness3. Effective use of language4. Effective information presentation
MU > Quality > CDS at POC > Problem List
MU > Quality > CDS at POC > Problem List > Simplicity
Simplicity
MU > Quality > CDS at POC > Problem List > Simplicity
The old way...
MU > Quality > CDS at POC > Problem List > Simplicity
Better way
MU > Quality > CDS at POC > Problem List > Naturalness
Naturalness
… but alphabeticallyNot by diagnosis code..
Sort & sequence like clinicians think
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?
MU > Quality > CDS at POC > Problem List > Info Prez
Effective Info Presentation
Sorted for cardiologySorted alphabetically
Filtered for cardiology
MU > Quality > CDS at POC > Problem List > Info Prez
Effective Info Presentation
Highlighted for cardiology
Alerts
Usability principles1. Simplicity2. Efficiency3. Effective information presentation
MU > Quality > CDS at POC > Alerts
MU > Quality > CDS at POC > Alerts > Simplicity
Too busy visually…
MU > Quality > CDS at POC > Alerts > Simplicity
Try to find the essence…
MU > Quality > CDS at POC > Alerts > Simplicity
All the doctor needs to see
MU > Quality > CDS at POC > Alerts > Simplicity
Simplicity
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
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
Lab results
Usability principles1. Effective information presentation2. Minimize cognitive load3. Preservation of context
MU > Quality > CDS at POC > Lab
MU > Quality > CDS at POC > Lab > Info Presentation
Effective info presentationold
new
MU > Quality > CDS at POC > Lab > Min cognitive load
Minimize cognitive load
MU > Quality > CDS at POC > Lab > Preserve context
Preservation of context
Compare to prior lab, two year graphical trend
MU > Quality > CDS at POC > Lab > Preserve context
And what medication is he/she on?And what is the weight and BP doing?
Registries
examples…
MU > Quality > Registries
Quality Registry: Dashboard
Usability principles1. Efficient interactions2. Effective information presentation
MU > Quality > CDS at POC > Problem List
Diabetes quality dashboard
MU > Quality > Registries > Quality dashboard
Efficient interactions
MU > Quality > Registries > Quality dashboard
Give actionable info at Point-of-Care
Engaging PatientsGiving e-access to health records
examples…
MU > Engaging Patients > Access to health record
Clinical Summary
Usability principles1. Effective use of language2. Efficient interactions
MU > Engage patients
Clinical Summary at Visit
MU > Engage patients > Clinical summary
A take-home for the patient
MU > Engage patients > Clinical summary
MU > Engage patients > Clinical summary
Effective Language
Plain English
MU > Engage patients > Clinical summary
And something for
the wallet
Efficient
MU > Engage patients > View lab on web
Viewing lab results on web
Usability principles1. Effective use of language2. Effective information presentation
MU > Engage patients > View lab on web
Viewing lab results on web
MU > Engage patients > View lab on web
Effective Language
Change ”Reference” to ”Normal Range”
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
MU > Engage patients > View lab on web
Effective Info Presentation
Easy to misunderstand “which normal range”
Web Access or e-Copy
Usability principles1. Naturalness2. Forgiveness
MU > Engage patients > e-Copy
Naturalness
MU > Engage patients > e-Copy
Forgiveness
MU > Engage patients > e-Copy
Shopping for usabilityEMR Buyer’s Guide
Before you buy, or implement…
Define what’s Important to You• Evaluate your alternatives• Select the alternative that is best for your team
MU > Before you buy
It’s a process…
Effectiveness•What do you want /need from your EMR? •How will this product meet those wants / needs? •See barriers when you try the product?
MU > Before you buy
What’s important to you
Efficiency•What outcomes should be better
• Faster• more robust• have better payoff
MU > Before you buy
What’s important to you
Satisfaction•Of which users?•For which key tasks?•In which clinical setting or environment?
MU > Before you buy
What’s important to you
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.
Evaluate Your Alternatives
MU > Before you buy
What do your colleagues say• Blogs, etc.
What do your professional groups & others say• KLAS• AAFP• Your state’s academy of …
Evaluate Your Alternatives
MU > Before you buy
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
MU > Before you buy
Evaluate Your Alternatives
Creating Clinical Scenarios
1.Choose ones that matter• frequent, important• Include prescribing• Include “hey-doc” request
2.Test them3.Look for efficiencies
• e.g. document normal ROS with one click
MU > Before you buy
Buyer BewareTry 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
MU > Before you buy
Buyer BewareDon’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!
MU > Before you buy
Buyer BewareTraining
• Touch on initial training • you & staff will be overwhelmed at launch
• Demand later training• after you have the basics down
MU > Before you buy
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
Questions?ARRA & Usability: What Providers Need to Know
Janey Barnes PhD | [email protected] Belden MD | [email protected]
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 | [email protected] Belden MD | [email protected]