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 | jbarnes@user-view.comJeff Belden MD | beldenj@health.missouri.edu

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.comJeff Belden MD | beldenj@health.missouri.edu