Usability and Human Factors

1. Usability and Human Factors Electronic Health Records and Usability Lecture b This material(Comp15_Unit6) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003. This material was updated by The University of Texas Health Science Center at Houston under Award Number 90WT0006. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

2. Electronic Health Records and UsabilityLecture b – Learning Objectives • Identify a set of well-established principles of usability and design and describe their application to EHRs (Lecture b) • Identify and explain usability methods for enhancing efficiency of use and minimizing likelihood of user error(Lecture b)

3. General Design Principles for EHRs • Consistency and standards • Visibility of system state • Match between system and world • Minimalist design • Minimize memory load • Informative feedback • Flexibility and efficiency • Good error messages • Prevent errors • Clear closure • Reversible actions • Use the user’s language • Users in control • Help and documentation National Center for Cognitive Informatics & Decision Making in Healthcare. (n.d.) Principles.

4. 1. Consistency & Standards National Center for Cognitive Informatics & Decision Making in Healthcare. (n.d.) Consistency and Standards.

5. 1. Consistency & Standards(Cont’d – 1) Belden, J. (2010).

6. 2. Visibility of System State National Center for Cognitive Informatics & Decision Making in Healthcare. (n.d.) Visibility of System State.

7. 2. Visibility of System State (Cont’d – 1) National Center for Cognitive Informatics & Decision Making in Healthcare. (n.d.) Visibility of System State.

8. 3. Match Between System and World National Center for Cognitive Informatics & Decision Making in Healthcare. (n.d.) Match between system and the real world.

9. 4. Minimalist Design • Any extraneous content is a distraction and a slow-down, which should be avoided to facilitate efficient action. • The EHR should only present information that is needed by users. • Displaying too much irrelevant information may distract users and therefore diminish the relative visibility of important information.

10. 4. Minimalist Design (Cont’d – 1) National Center for Cognitive Informatics & Decision Making in Healthcare. (n.d.) Minimalist Design.

11. 4. Minimalist Design (Simplicity) Belden, J. (2010). Courtesy of Dr. Jeffrey Belden

12. 5. Minimize Memory Load National Center for Cognitive Informatics & Decision Making in Healthcare. (n.d.) Minimize Memory Load.

13. 5a. Minimize Cognitive Load • Perception, attention, memory are limited • Less attention to system means more available for medical tasks • Present all information needed for task on same screen • Decrease memory use • Recognition, not recall

14. 5a. Minimize Cognitive Load (Cont’d – 1) • Organize by meaningful relationships • Decrease excessive navigation • Transparency: • Don’t make the user wonder “How do I? Where is…?”, “What does this do..?” • Adequate cues for data entry • Perception, not computation • e.g. visual display

15. 5a. Minimize Cognitive Load (Cont’d – 2) • Same information presented graphically allows easy detection of patterns & perception, not calculation Senathirajah,Y. (2010).

16. 5a. Minimizing Cognitive Load Belden, J. (2010).

17. 5a. Minimizing Cognitive Load (Cont’d – 1) Belden, J. (2010).

18. 5a. Minimizing Cognitive Load (Cont’d – 2) Belden, J. (2010).

19. 6. Provide Informative Feedback National Center for Cognitive Informatics & Decision Making in Healthcare. (n.d.) Provide Informative Feedback.

20. 6. Provide Informative Feedback (Cont’d – 1) • Alerts: should be given by the system when users’ actions are incorrect or have good likelihood of causing errors • The appropriate use of alerts can greatly reduce the potential of errors • Messages should: • Be expressed in plain language • Precisely indicate the problem, and • Constructively suggest a solution

21. 6. Provide Informative Feedback (Cont’d – 2) National Center for Cognitive Informatics & Decision Making in Healthcare. (n.d.) Provide Informative Feedback.

22. 7. Flexibility and Efficiency • Flexible functions • Shortcuts • Search functions • Auto tabbing, good defaults, appropriately changeable, limit scrolling (e.g large text/list boxes), prevent switch between keyboard and mouse • Minimize visual search • Minimize distance cursor travels (Fitt’s law) • Both lead to user fatigue & frustration

23. Dashboard Efficiency Belden, J. (2010).

24. 8. Good Error Messages • Users will click through practically anything if they see it often enough. • The phenomenon of clicking OK or Dismiss without reading the text is called alert fatigue. • Messages should be informative to the user and in a human readable format. • The user should be able to understand the nature of error, learn from the message, and recover a specific error.

25. 9. Prevent Errors • 2 categories of errors: • Slips • Mistakes • Slips result from automatic behavior, when subconscious actions intended to satisfy a goal are waylaid • Mistakes result from conscious deliberation- the choice of inappropriate goals / poor decisions • Most everyday errors are slips (Norman, 1990, p. 105-113)

26. 9. Prevent Errors (Cont’d – 1) National Center for Cognitive Informatics & Decision Making in Healthcare. (n.d.) Error Prevention.

27. 10. Clear Closure • Well-defined beginning and end • Users should be unambiguously notified that a task is completed. • The transparent feedback to the user indicates when a goal has been achieved.

28. 11. Reversible Actions • Users should be allowed to recover from errors • Can be at different levels • a single action • a subtask • a complete task and in multiple steps • Encourages exploratory learning • Prevents serious errors

29. 12. Use the User’s Language • Concise, unambiguous, familiar to users • Not computer terminology • Not upper case except in rare contexts • Only commonly understood abbreviations and acronyms

30. 12. Use the User’s Language (Cont’d – 1) • Indicate clearly further information • e.g. ellipsis… • JCAHO has list of forbidden abbreviations (can cause errors) • Presentation of structured terminology is complex, area of research • Structured terms used for many functions: • DS, eliminating redundancy, admin/reporting, identify clinical relationships, etc.

31. Other: Effective Information Presentation • Appropriate density: • Myth: less dense is better • Staggers 1997: nursing interface had more efficiency/lower errors with more density • Key is less visual search, organization, drill-down/summarization as appropriate • Juxtaposition of related items • e.g. INR/coumadin, systolic and diastolic together

32. Effective Info Presentation Belden, J. (2010).

33. Other: Color • Color: use to convey meaning, not decoration • Consistency of color meaning • Use number of colors user can remember • Don’t contradict conventions • e.g. red=danger, stop; green=ok, go • Section 508: 8% of male users are colorblind • Convey color meaning with a secondary method • e.g. underlining

34. Color Meanings (US) • Red: • Stop, Hot, Danger, Error, Extreme Warning, Severe Alert, Emergency, Alarm • Yellow: • Caution, Potential or Mild Warning, Requires Attention, Slow, Moderate Alert • Green: • Go, Safe, Normal, Good, Proceed • Blue: • Cold, Advisory

35. Other: Readability • Must be able to scan quickly with high comprehension • 12 point or greater, always >9point • Allow users to change font size • Visual impairments in much of the population • i.e. respect system settings for color, size, font • Sans serif most readable on computer screens • Black on white most readable

36. Other: Preservation of Context • Interruptions abound • Minimize visual interruptions • Direct responsiveness • i.e. user should be able to tell immediately what is happening • Avoid ‘modes’ • e.g. data entry mode v. viewing • Data entry should be directly available if allowed

37. Preservation of Context Belden, J. (2010).

38. Preservation of Context (Cont’d – 1) Belden, J. (2010).

39. Healthcare Usability Maturity Model • HIMSS released a report February 8th, 2011 • Promoting usability in health organizations • Initial steps and progress toward a healthcare usability maturity model • Comprehensive background and plan for promoting usability in organizations, including 3 case examples • 5-stage model: • Unrecognized • Preliminary • Implemented • Integrated • Strategic

40. Stages of Usability with Respect to Organizational Processes (Staggers, n.d.)

41. Common Methods for Launching Usability in Organizations • “Wake-up Calls” • Critical incidents that start a change • Individual infiltration methods • Slow talking to various teams, user groups, managers • Finding internal champions • Can be at any level, but usability must be presented as an advantage for the organization’s mission • e.g. efficiency, patient safety, effectiveness • Using external experts as a catalyst • Can be useful, and faster than developing internal expertise

42. Common Methods of Expanding Usability within Organizations (Staggers, n.d.)

43. Value of Usability to Health Organizations (Staggers, n.d.)

44. Basic Methods • Don't just listen to the executives • Listen to the users • Don't listen to what they say • Listen to what they do • Don't give them what they ask for • Give them what they need

45. Continuum of Usability

46. Electronic Health Records and Usability Summary – Lecture b • Usability concepts and cognitive loads • Examples of efficient iterations and effective use of language • Stages of usability with respect to organizational processes • Usability overflow and basic methods

47. Electronic Health Records and UsabilityReferences – Lecture b References General Design Principles for EHRs - National Center for Cognitive Informatics & Decision Making in Healthcare. . (n.d.). Retrieved June 12, 2016, from https://sbmi.uth.edu/nccd/ehrusability/design/guidelines/Principles/index.htm Norman, D.A. The Design of Everyday Things. 1990. Currency/Doubleday. Images Slide 4: National Center for Cognitive Informatics & Decision Making in Healthcare. (n.d.) Consistency and Standards. Retrieved from https://sbmi.uth.edu/nccd/ehrusability/design/guidelines/Principles/consistency.htm Slides 5, 11, 16, 17, 18, 23, 32, 37, 38: Belden, J. (2010). Usability in Health IT: Technical Strategy, Research, and Implementation, National Institute of Standards and Technology Gaithersburg, MD, July 13, 2010. http://www.nist.gov/itl/upload/Final-Agenda-Usability-in-Health-IT-2.pdf Slides 6, 7: National Center for Cognitive Informatics & Decision Making in Healthcare. (n.d.) Visibility of System State. Retrieved from https://sbmi.uth.edu/nccd/ehrusability/design/guidelines/Principles/visibility.htm Slide 8: National Center for Cognitive Informatics & Decision Making in Healthcare. (n.d.) Match between system and the real world. Retrieved from https://sbmi.uth.edu/nccd/ehrusability/design/guidelines/Principles/match.htm. Slide 10: National Center for Cognitive Informatics & Decision Making in Healthcare. (n.d.) Minimalist Design. Retrieved from https://sbmi.uth.edu/nccd/ehrusability/design/guidelines/Principles/minimal.htm. Slide 11: Jeffrey Belden. TooManyClicks Blog. (2016). TooManyClicks. Retrieved 30 June 2016, from http://www.toomanyclicks.com Slide 12: National Center for Cognitive Informatics & Decision Making in Healthcare. (n.d.) Minimalist Design. Retrieved from https://sbmi.uth.edu/nccd/ehrusability/design/guidelines/Principles/memory.htm Slide 15: Senathirajah,Y. (2010). Example of kidney function creatinine. Unpublished manuscript. Slides 19, 21: National Center for Cognitive Informatics & Decision Making in Healthcare. (n.d.) Provide Informative Feedback. Retrieved from https://sbmi.uth.edu/nccd/ehrusability/design/guidelines/Principles/feedback.htm Slide 26: National Center for Cognitive Informatics & Decision Making in Healthcare. (n.d.) Error Prevention. Retrieved from https://sbmi.uth.edu/nccd/ehrusability/design/guidelines/Principles/prevention.htm Slides 40, 42, 43: Staggers, N. HIMSS Usability Task Force. (n.d.) Promoting Usability in Health Organizations Using a Healthcare Usability Maturity Model. Retrieved from http://www.nist.gov/healthcare/usability/upload/NIST_Promoting_Usability_Nancy_Staggers.pdf

48. Usability and Human FactorsElectronic Health Records and UsabilityLecture b This material was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003. This material was updated by The University of Texas Health Science Center at Houston under Award Number 90WT0006.