User Interaction Design and Emergency Department WorkflowUser Interaction Design and User Interaction Design and Emergency Department Emergency Department WorkflowWorkflow

A Worst-Case Scenario for Developers

Keith Conover, M.D., FACEPMercy Hospital, Pittsburgh

University of Pittsburgh

A Worst-Case Scenario for Developers

Keith Conover, M.D., FACEPMercy Hospital, Pittsburgh

University of Pittsburgh

Presentation available atwww.pitt.edu/~kconoverPresentation available atwww.pitt.edu/~kconover

• Emergency Department characteristics

• ED staff characteristics• Error vs. computers• Usability and User

Interaction Design (“User Interface”) Principles

• CPOE in the ED• Books and websites

• Emergency Department characteristics

• ED staff characteristics• Error vs. computers• Usability and User

Interaction Design (“User Interface”) Principles

• CPOE in the ED• Books and websites

OutlineOutlineOutline

ED CrowdingED CrowdingED Crowding

1. Richardson LD, Asplin BR, Lowe RA. Emergency department crowding as a health policy issue: past development, future directions. Ann Emerg Med 2002;40(4):388-93.

2. General Accounting Office. Hospital emergency departments: Crowded conditions vary among hospitals and communities. Washington, DC: General Accounting Office; 2003. Report No.: GAO-03-460.

1. Richardson LD, Asplin BR, Lowe RA. Emergency department crowding as a health policy issue: past development, future directions. Ann Emerg Med 2002;40(4):388-93.

2. General Accounting Office. Hospital emergency departments: Crowded conditions vary among hospitals and communities. Washington, DC: General Accounting Office; 2003. Report No.: GAO-03-460.

(From critical incident stress training materials for

search and rescue)

(From critical incident (From critical incident stress training materials for stress training materials for

search and rescue)search and rescue)

Emergency services workers:– have obsessive/compulsive personality traits– like to be in control– are risk oriented– are action-oriented– “need to be needed”– are dedicated

Emergency services workers:–– have have obsessive/compulsive obsessive/compulsive personality traitspersonality traits–– like to be like to be in controlin control–– are are risk orientedrisk oriented–– are are actionaction--orientedoriented–– ““need to be neededneed to be needed””–– are are dedicateddedicated

Interrupt-driven, Multi-tasking

InterruptInterrupt--driven, driven, MultiMulti--taskingtasking

Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: are emergency physicians "interrupt-driven" and "multitasking"? Acad Emerg Med 2000;7(11):1239-43.

Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: are emergency physicians "interrupt-driven" and "multitasking"? Acad Emerg Med 2000;7(11):1239-43.

Error vs. ComputersError vs.

Computers

Error in MedicineError in

Medicine

100,000 Avoidable

Deaths a Year

Harvard Medical Practice Study,

1984

100,000 100,000 Avoidable Avoidable

Deaths a Deaths a YearYear

Harvard Medical Harvard Medical Practice Study, Practice Study,

19841984

Institute of Medicine:

“To Err is Human”

Institute Institute of Medicine:of Medicine:

““To Err is To Err is HumanHuman””

• Institute of Medicine• Part of National

Academy of Science• “To Err is Human:

Building a Safer Health System” 2000

• Institute of Medicine• Part of National

Academy of Science• “To Err is Human:

Building a Safer Health System” 2000

Computers will Change Your Future!!!!!!!!!!!!!!!

Computers will Change Computers will Change Your Future!!!!!!!!!!!!!!!Your Future!!!!!!!!!!!!!!!

How ED Staff View HIS Systems

(courtesy Alan Cooper)

How ED Staff View How ED Staff View HIS SystemsHIS Systems

(courtesy Alan Cooper)(courtesy Alan Cooper)

Usability and

Design

Usability and

Design

Usability & Interface

Usability & Usability & InterfaceInterface

Hide The Ejector Seat Levers

Hide The Ejector Hide The Ejector Seat LeversSeat Levers

48% of Recent Software Code is Interface

48% of Recent Software 48% of Recent Software Code is InterfaceCode is Interface

Nielsen J. Usability Engineering. Academic Press, 1993

Implementation vs.Mental Models

Implementation vs.Mental Models

Goal-Directed DesignGoal-Directed Design• Not looking stupid• Not making any big mistakes• Getting an adequate amount

of work done• Having fun

(or at least not being too bored)

Goal-Directed DesignGoal-Directed Design

Learning CurvesLearning CurvesE

ffort

Effo

rt

ResultsResults

Learnability/ MemorabilityLearnability/ Memorability

• Learnability:– ISO: icons interpreted correctly by 2/3 of subjects– 6/12 by knowledgeable users; 1/12 by new users

• Washington, D.C.: “Park and Ride” signs– Good Learnability– Excellent Memorability

• “Kiss and Ride” signs– Poor Learnability, but– Excellent Memorability

• Learnability:–– ISO: icons interpreted correctly by 2/3 of subjectsISO: icons interpreted correctly by 2/3 of subjects–– 6/12 by knowledgeable users; 1/12 by new users6/12 by knowledgeable users; 1/12 by new users

• Washington, D.C.: “Park and Ride” signs–– Good LearnabilityGood Learnability–– Excellent MemorabilityExcellent Memorability

• “Kiss and Ride” signs–– Poor Learnability, butPoor Learnability, but–– Excellent MemorabilityExcellent Memorability

Lindgaard G, Chessari J, Ihsen E. Australian Telecommunications

Research 21(2):17-29

Response TimeResponse TimeResponse Time

• Feeling of direct manipulation: 0.1 second– Longer, and no feeling of control

• “Waiting for computer”: 1 second– Longer, and users restrict use of system

--Nielsen, Jakob. Designing Web Usability

• Much worse in ED

• Feeling of direct manipulation: 0.1 second–– Longer, and no feeling of controlLonger, and no feeling of control

• “Waiting for computer”: 1 second–– Longer, and users restrict use of systemLonger, and users restrict use of system

----Nielsen, Jakob. Designing Web UsabilityNielsen, Jakob. Designing Web Usability

• Much worse in ED

Design IntegrityDesign IntegrityDesign Integrity

“Objects constructed

from genuine materials are

always valued more highly than those that use a

cheaper substitute”

“Objects constructed

from genuine materials are

always valued more highly than those that use a

cheaper substitute”

Mullet K, Sano D.Designing Visual

Interfaces: Communication Oriented Techniques

Sunsoft, 1995

Design IntegrityDesign IntegrityDesign Integrity

Japanese Kanban Signs

Japanese Japanese KanbanKanban SignsSigns

• Shibui:subdued beauty

• Wabi:elegant simplicity

• Shibui:subdued beauty

• Wabi:elegant simplicity

Mullet K, Sano D.Designing Visual

Interfaces: Communication Oriented Techniques

Sunsoft, 1995

Abstraction and Simplicity in Design

Abstraction and Abstraction and Simplicity in DesignSimplicity in Design

Mullet K, Sano D.Designing Visual

Interfaces: Communication Oriented Techniques

Sunsoft, 1995

Taped-On InstructionsTapedTaped--On On

InstructionsInstructions

Mullet K, Sano D.Designing Visual

Interfaces: Communication Oriented Techniques

Sunsoft, 1995

Like the presence of taped-on instructions in the physical workplace, the presence of help text in the interface is itself a reliable indicator of flaws in the underlying design.

Screen DesignScreen DesignScreen DesignMullet K, Sano D.Designing Visual

Interfaces: Communication Oriented Techniques

Sunsoft, 1995

Test Time! Have you been awake?

Test Time! Have you Test Time! Have you been awake?been awake?

• Which of the two following notebook-metaphor interfaces is a Stickley chair, and which is wood-grain vinyl?

• Why?

• Which of the two following notebook-metaphor interfaces is a Stickley chair, and which is wood-grain vinyl?

• Why?

Changing One WordChanging One WordChanging One Word

• NEXUS cervical-spine clearing failures in EMS: wording changed

• Signature block for standing orders

• NEXUS cervical-spine clearing failures in EMS: wording changed

• Signature block for standing orders

Changing One WordChanging One WordChanging One Word

Tognazzini’sParadox

TognazziniTognazzini’’ssParadoxParadox

Problem: find out if user has a color monitor

1. Are you using a color monitor?

2. Is the picture above in color?Failure: 25%

Problem: find out if user has a color monitor

1. Are you using a color monitor?

2. Is the picture above in color?Failure: 25%

3.

Are the words above in color?Color: 0%. B+W: 0%. Green: 100%.

3.

Are the words Are the words

above in color?above in color?

Color: 0%. B+W: Color: 0%. B+W: 0%. Green: 100%.0%. Green: 100%.

Tognazzini, B (“Tog”). TOG on Interface.1992; Reading, MA: Addison-

Wesley.

Green

Blue

Orange

Magenta

Tognazzini’sParadox

TognazziniTognazzini’’ssParadoxParadox

4.

Are the words above in more than one color?Color: 0%. B+W: 20%. Green: 50%.

4.

Are the words above in more than one color?Color: 0%. B+W: 20%. Green: 50%.

5. Are the words above in several different colors?Color: 0%. B+W: 20%. Green: 25%.

6. Do the words above appear in several different colors?0% failure!

5. Are the words above in several different colors?Color: 0%. B+W: 20%. Green: 25%.

6. Do the words above appear in several different colors?0% failure!

Green

Blue

Orange

Magenta

Users are Not DesignersUsers are Not Designers

“Leaving the design to the users is the ultimate abdication of the designer’s responsibility to provide a quality product, and many studies have shown that users…customize their interface in ways that are detrimental to their productivity.”

“Leaving the design to the users is the ultimate abdication of the designer’s responsibility to provide a quality product, and many studies have shown that users…customize their interface in ways that are detrimental to their productivity.”

Jakob Nielsen, Foreword to Mullet K, Sano D.

Designing Visual Interfaces.

Customizable Tracking Board?

Customizable Tracking Board??

“Users can click on any column heading to sort by that category, can drag the lines to make columns wide or narrow, or even hide them altogether.”

“Users can click on any column heading to sort by that category, can drag the lines to make columns wide or narrow, or even hide them altogether.”

Usability PearlsUsability Pearls

• Your Best Guess is Not Good Enough

• The User Is Always Right

• The User Is Not Always Right

• Users are Not Designers

• Your Best Guess is Not Good Enough

• The User Is Always Right

• The User Is Not Always Right

• Users are Not Designers

Nielsen J. Usability Engineering.

Academic Press, 1993

• Designers are Not Users • Vice Presidents

are Not Users• Less Is More• Details Matter • Help Doesn’t• Usability Engineering

Is Process

• Designers are Not Users • Vice Presidents

are Not Users• Less Is More• Details Matter • Help Doesn’t• Usability Engineering

Is Process

PosturePostureSovereign Posture:– Takes over entire screen– Expects to be solely in

charge of the computer and the user

– E.g., word processor, spreadsheet

Daemonic Posture– Only needs a little bit of

screen– just one of many things

getting attention from computer and user

– E.g., modem dialup applet

Sovereign Posture:–– Takes over entire screenTakes over entire screen–– Expects to be solely in Expects to be solely in

charge of the computer and charge of the computer and the userthe user

–– E.g., word processor, E.g., word processor, spreadsheetspreadsheet

Daemonic Posture–– Only needs a little bit of Only needs a little bit of

screenscreen–– just one of many things just one of many things

getting attention from getting attention from computer and usercomputer and user

–– E.g., modem E.g., modem dialupdialup appletapplet

“Coke Machine” = kiosk = “drive-through” posture– Takes over entire screen– Expects to be solely in charge– Always the same whenever

anyone walks up to it– Interface is extremely simple,

learnable, memorable

“Coke Machine” = kiosk = “drive-through” posture–– Takes over entire screenTakes over entire screen–– Expects to be solely in chargeExpects to be solely in charge–– Always the same whenever Always the same whenever

anyone walks up to itanyone walks up to it–– Interface is extremely simple, Interface is extremely simple,

learnable, memorablelearnable, memorable

CPOE in the ED?CPOE in the ED?CPOE in the ED?

• $450 million hospital HIS failure VA Hospital at Bay Pines, Florida

• Deinstall of CPOE at Cedars-Sinai due to “physician revolt”

• Dr. David Classen of First Consulting Group says > 6 other hospitals also deinstalled HIS

• $450 million hospital HIS failure VA Hospital at Bay Pines, Florida

• Deinstall of CPOE at Cedars-Sinai due to “physician revolt”

• Dr. David Classen of First Consulting Group says > 6 other hospitals also deinstalled HIS

CPOE in the ED?CPOE in the ED?CPOE in the ED?

• At EDIS 2005 deinstallation forum: multiple complaints that a major HIS vendor’s ED module totally unusable.

• Rush in Chicago has CPOE everywhere—except in the ED.

• Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005;293(10):1197-203.

• At EDIS 2005 deinstallation forum: multiple complaints that a major HIS vendor’s ED module totally unusable.

• Rush in Chicago has CPOE everywhere—except in the ED.

• Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005;293(10):1197-203.

Nielsen on KoppelNielsen on Nielsen on KoppelKoppel

ED Niche VendorsED Niche VendorsED Niche Vendors

• Most EDs with CPOE do so through an ED “Niche” vendor’s system

• Niche vendors understand– ED crowding– ED staff– ED workflow– User interface design

• Most EDs with CPOE do so through an ED “Niche” vendor’s system

• Niche vendors understand–– ED crowdingED crowding–– ED staffED staff–– ED workflowED workflow–– User interface designUser interface design

Standing OrdersStanding OrdersStanding Orders

Computer-based Standing Orders better than reminders for enforcing standards and preventing omission errors:

Dexter PR, Perkins SM, Maharry KS, Jones K, McDonald CJ. Inpatient computer-based standing orders vs physician reminders to increase influenza and pneumococcal vaccination rates: a randomized trial. JAMA 2004;292(19):2366-71.

Computer-based Standing Orders better than reminders for enforcing standards and preventing omission errors:

Dexter PR, Perkins SM, Maharry KS, Jones K, McDonald CJ. Inpatient computer-based standing orders vs physician reminders to increase influenza and pneumococcal vaccination rates: a randomized trial. JAMA 2004;292(19):2366-71.

Books and

Websites

Books and

Websites

Mullet K, Sano D.

Designing Visual Interfaces:

Communication Oriented

TechniquesSunsoft, 1995

Mullet K, Sano D.

Designing Visual Interfaces:

Communication Oriented

TechniquesSunsoft, 1995

Nielsen J. Usability

Engineering. Academic

Press, 1993

Nielsen J. Usability

Engineering. Academic

Press, 1993

[Stalin’s Statue]:Next Slide, Please![Stalin[Stalin’’s Statue]:s Statue]:

Next Slide, Please!Next Slide, Please!

For re-education campaigns, nothing is

better than the Autocontent Wizard!

For re-education campaigns, nothing is

better than the Autocontent Wizard!

Comrade, why are we having this meeting? The

rate of information transfer is asymptotically

approaching zero!

Comrade, why are we having this meeting? The

rate of information transfer is asymptotically

approaching zero!

Military Parade, Stalin Square, Budapest, April 4, 1956Military Parade, Stalin Square, Budapest, April 4, 1956

An integrated application solution for

show trials!

An integrated application solution for

show trials!

There’s no bullet list like Stalin’s

bullet list!

There’s no bullet list like Stalin’s

bullet list!

But why read aloud EVERY slide?

But why read aloud EVERY slide?

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Annual National Symposium on Emergency Department Information Systemsfrom the Pennsylvania Chapter of the American College of Emergency Physicians

One Domain - One Source for all your EDIS Solutions / PaACEP isEDIS

isEDIS.com

December 5-8, 2005 Doubletree Paradise Valley Resort Scottsdale, AZ

• EDs: crowded, busy• ED staff: action-oriented, interrupt-driven• Error vs. computers: oversell?• Usability and User Interaction Design Principles

– Hiding the ejector seat levers– Mental vs. implementation models– Goal-directed design– Learnability vs. memorability– Response time– Design integrity– Abstraction and simplicity– Tognazzini's paradox– Posture

• CPOE in the ED: standing orders• Books and websites

• EDs: crowded, busy• ED staff: action-oriented, interrupt-driven• Error vs. computers: oversell?• Usability and User Interaction Design Principles

–– Hiding the ejector seat leversHiding the ejector seat levers–– Mental vs. implementation modelsMental vs. implementation models–– GoalGoal--directed designdirected design–– Learnability vs. memorabilityLearnability vs. memorability–– Response timeResponse time–– Design integrityDesign integrity–– Abstraction and simplicityAbstraction and simplicity–– Tognazzini'sTognazzini's paradoxparadox–– Posture Posture

• CPOE in the ED: standing orders• Books and websites

It seems so obvious…It seems so obviousIt seems so obvious……

Challenge = OpportunityChallenge = OpportunityChallenge = Opportunity

• The ED is intolerant of stupidity • The ED is intolerant of poor usability.• The ED is intolerant of inefficiency.• The ED is intolerant of poor user

interaction design.• The ED is intransigent.• But if you can make it work in the ED,

you can make it work anywhere.

• The ED is intolerant of stupidity • The ED is intolerant of poor usability.• The ED is intolerant of inefficiency.• The ED is intolerant of poor user

interaction design.• The ED is intransigent.• But if you can make it work in the ED,

you can make it work anywhere.

Presentation available atwww.pitt.edu/~kconover

Thank you!

Presentation available atwww.pitt.edu/~kconover

Thank you!