1. ARRA and
EMR Usability
What 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.

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

3. Really big c
oncern
Low EMR Adoption Rates

4. EMR Adoption Hospitals - 2008
100%
Full Basic Basic without None
clinician notes
AK Jha et al, NEJM 2009
EMR Adoption Doctor Offices – 2007-08
100%
Full Basic None
CM DesRoches et al, NEJM 2008

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

6. Usability missing
Smelcer 2009
EMR
What is ^usability?

7. Usability is
Effectiveness
Efficiency
Satisfaction
ISO 2003
Usability means
Learnable
Efficient
Memorable
Error-free
Satisfying
Useit.com

8. Current EMRs
lack good usability
Smelcer 2009
examples

9. Time consuming
dictation takes 33 seconds
EMR can take 10x longer
Alert Fatigue
of high-priority DDI alerts…
90% ignored

10. Complex steps
hard to learn
Longer, costly training
AAFP EMR Survey 2009
User satisfaction ratings
from 2,012 Family Physicians

12. Usability is…
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

13. Simplicity
Simplicity
For doing refills
For overview only

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

15. Naturalness
Better way
we know the body
already
Consistency

16. Consistency
Name and identifying info consistently placed
Minimizing Cognitive Load

17. Minimizing Cognitive Load
Exact past dates
• This requires mental math
Minimizing Cognitive Load
Relative past dates
• Easier. No extra thinking.

18. Minimizing Cognitive Load
Hover to see more detail
• Have it both ways
Efficient Interactions

19. Efficient Interactions
Dashboard efficiency
Efficient Interactions
50 Clicks…
• 6 minutes

20. 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

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

22. Forgiveness
Let users discover by
exploring without fear of destroying
Let users recover gracefully from
mistakes
Forgiveness
A bad example…

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

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

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

26. Effective Use of Language
Terse for doctor
Plain English for patient

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

28. Preservation of Context
Preservation of Context

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

30. 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
MU > Improve Quality
1. Improve Quality…
1. Evidence-based CPOE
2. Clinical decision support at the Point-of-care
3. Registries for patient outreach

31. MU > Quality > EBM CPOE
Evidence-based CPOE
…building ruts to quality & safety
examples…
MU > Quality > EBM CPOE
Antibiotic Selection for
Community-Acquired Pneumonia
Usability principles
1. Simplicity
2. Efficient interactions
3. Minimizing cognitive load

32. MU > Quality > EBM CPOE
MU > Quality > EBM CPOE > Simplicity
Simplicity

33. MU > Quality > EBM CPOE > Min cognitive load
Minimize cognitive load
MU > Quality > EBM CPOE > Efficient
Efficient interactions

34. MU > Quality > CDS at POC
Clinical Decision Support
at the Point of Care
examples…
MU > Quality > CDS at POC > Problem List
Problem Lists
Usability principles
1. Simplicity
2. Naturalness
3. Effective use of language
4. Effective information presentation

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

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

37. 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 alphabetically Sorted for cardiology

38. MU > Quality > CDS at POC > Problem List > Info Prez
Effective Info Presentation
Highlighted for cardiology Filtered for cardiology
MU > Quality > CDS at POC > Alerts
Alerts
Usability principles
1. Simplicity
2. Efficiency
3. Effective information presentation

39. MU > Quality > CDS at POC > Alerts > Simplicity
Too busy visually…
MU > Quality > CDS at POC > Alerts > Simplicity
Try to find the essence…

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

41. 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

42. MU > Quality > CDS at POC > Lab
Lab results
Usability principles
1. Effective information presentation
2. Minimize cognitive load
3. Preservation of context
MU > Quality > CDS at POC > Lab > Info Presentation
Effective info presentation
old
new

43. 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

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

45. MU > Quality > CDS at POC > Problem List
Quality Registry: Dashboard
Usability principles
1. Efficient interactions
2. Effective information presentation
MU > Quality > Registries > Quality dashboard
Diabetes quality dashboard

46. MU > Quality > Registries > Quality dashboard
Efficient interactions
Give actionable info at Point-of-Care
MU > Engaging Patients > Access to health record
Engaging Patients
Giving e-access to health records
examples…

47. MU > Engage patients
Clinical Summary
Usability principles
1. Effective use of language
2. Efficient interactions
MU > Engage patients > Clinical summary
Clinical Summary at Visit
A take-home for the
patient

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

49. MU > Engage patients > Clinical summary
Efficient
And
something for
the wallet
MU > Engage patients > View lab on web
Viewing lab results on web
Usability principles
1. Effective use of language
2. Effective information presentation

50. 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”

51. 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”

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

53. MU > Engage patients > e-Copy
Forgiveness
EMR Buyer’s Guide
Shopping for usability
Before you buy, or implement…

54. 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
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?

55. 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?

56. 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.
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 …

57. 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
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

58. 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
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!

59. 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

60. 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
ARRA & Usability: What Providers Need to Know
Questions?
Janey Barnes PhD | jbarnes@user-view.com
Jeff Belden MD | beldenj@health.missouri.edu

61. 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