Name: Art

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Bio: Art Swanson is the Director of User Experience for Allscripts, where he has responsibility for Mobility and Common User Interface Frameworks. Art has seven years' experience in healthcare IT and an additional seven years in Human Factors consulting in the medical, aviation, consumer electronics, and automotive industries. He has extensive experience in qualitative and quantitative research, generative research, affective design theory, and human motor control research.

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    Raise Your Hand if You Think You Understand Usability

    September 27th, 2012

    In my previous post, I didn’t address much of the industry discussion about Electronic Health Record (EHR) usability:  What, exactly, is usability in the first place?  How do you measure it? How do you improve it?

    These questions are important for a couple of reasons:

    • First, usability is a critical requirement for any software and should be a main focus of development.
    • Second, the Office of the National Coordinator (ONC) is establishing policy to attempt to improve EHR usability, making it a regulatory issue as well.

    Here’s some background on the second point for context.  When the government passed ARRA to help fund Health IT adoption, a primary issue raised by the healthcare community was that Health IT systems have many usability issues. So – as many people posed – if the government was going to mandate EHR adoption, shouldn’t the government also ensure usability?

    As a result, the ONC is under significant pressure to help improve EHR usability, but the complication that we have faced for decades is that usability is a compound construct.  It is composed of three primary measures:

    • efficiency (how quickly can I do something?),
    • effectiveness (how accurately can I do something?), and
    • satisfaction (how satisfied am I when doing something?)

    But this presents a challenge:  One person might identify that efficiency is the most important factor while another may decide satisfaction is more important.  And what makes different people satisfied is, of course, different.

    Considering this, the ONC (with AHRQ and NIST) decided that the only area it should regulate was safety (identified in the UX community as a component of effectiveness). As a result, there is a requirement in Stage 2 of the Meaningful Use EHR Incentive Program for a summative usability test.  This test is comprised of having representative users walk through a series of tasks and measuring the amount of time to complete the task, how many and what type of errors occur, and satisfaction with the task interaction.  But this measure does little to prove or ensure the safety of the system.

    As an example, a workflow could automatically dismiss DUR warnings when prescribing a medication.  By the letter of the Final Rule on certifying products for Stage 2, we could test this workflow where the user prescribes penicillin to a patient with a penicillin allergy.  In this test, the workflow might show that we have improved the efficiency (and arguably the clinician satisfaction) by dismissing an “annoying” alert, and it may have even improved the effectiveness (depending on how we defined the goal), but it could possibly have a very serious impact on safety. However, this test would be satisfactory under the MU 2 guidelines.

    If the goal is to improve the safety of the products, then we should consider models similar to those developed by the FDA.

    The FDA has worked on improving safety in medical devices for years, including the application of a Human Factors technique called a hazard analysis.  This is a process where all critical events are defined and categorized by a Human Factors professional.  These critical events are then back propagated through the design to determine when, where and how they could occur, leading manufacturers to design mitigations that ensure the critical events are as unlikely as possible. It’s a process that has proven highly effective in improving the safety of these systems.

    I’m not saying that what’s been developed by the FDA can be applied as is, because software development is different. But if the ONC is serious about improving the safety of these systems, then it needs to introduce measures and processes that will definitively improve the safety of these systems.  And, the ONC needs to be explicit about that priority and the potential impact on the products (which could include some negative impact to efficiency).

    The reality is that any government mandates into factors as esoteric as user satisfaction need to considered before implementation.  These are the areas that market forces are expert in changing, and we should allow those forces to make an impact without government intervention.  Usability is more complex than many people understand.  My suggestion to the ONC: tread lightly or we may all find ourselves dealing with unintended consequences.

    We at Allscripts are dedicated to the usability and safety of both our products, and the usability and safety of the industry as whole.  We will continue to monitor these efforts to ensure a pragmatic approach that has positive benefits for patients, clients, and the Health IT industry.

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    Time to Hit the Pause Button on Meaningful Use?

    September 13th, 2012

    That was one of the key questions raised in Tuesday’s Health IT Meaningful Usability Summit 2012 in Washington, DC, part of National Health IT Week.  The summit attracted representatives from government, academia, payers, healthcare IT vendors, and non-profits. I was there representing Allscripts, where I serve as Director of User Experience. The summit attendees focused on a handful of key points related to usability:  safety and usability; radical industry transformation; open and modular systems and data; and a consumer focus in Health IT. 

    Let’s take a quick look at each of them in turn before I return to that headline.

    Safety and usability

    Dr. Jacob Reider, the acting Chief Medical Officer for the Office of the National Coordinator for Healthcare IT (ONC), and a former CMO of Allscripts, gave a presentation on usability of health IT that focused on safety.  Dr Reider’s presentation was supported by several other presenters, including one of the authors of the recent Institute of Medicine report on Health IT and patient safety.  While the presentation was compelling, the topic raises questions for me, with my background in human factors.  Safety has been demonstrated to correlate with usability, but usability is not the only factor involved in safety.  Some facets of safety actually negatively impact usability (for instance, when you slow a user down to ensure they don’t make an error — one of the examples that Dr. Reider referenced in his presentation).  The FDA is the most knowledgeable resource on this topic, and their recommendations differ fairly significantly from those put forward by ONC.  Safe to say, this is an issue that will continue to be actively debated in the usability community, and I suspect that Meaningful Use Stage 3 will include stronger alignment between the ONC’s position on safety and the best practices instituted by the FDA.

    Radical Industry Transformation

    The summit included several presentations on the profound changes being driven by Affordable Care Act — the shift from fee-for-service to fee-for value, and the rapid improvements in technology that this transformation requires.  One interesting presentation was from a vice president at Aetna describing the company’s internal reform.  Aetna no longer considers itself an insurance company, he said.  Instead, the nation’s 5th largest health insurer considers itself a company devoted to fostering the assurance of health.  It’s a subtle but important distinction. He described their strategy of acquiring properties to assist in Aetna’s transformation, including a mobile app (iTriage) that helps consumers make better health decisions, and an HIE vendor (Medicity).  He also indicated Aetna is footing the bill for implementation and support of these systems for partners, which points to some direct competition with traditional HIT vendors (and lots of opportunity for us to work together).  I suspect that we will see more and more large companies start to shift their perspective on the healthcare market in the face of health reform. The insurance companies are just the first wave. 

    The Importance of Open and Modular Systems

    Several presentations were focused on this topic, as well as the importance of data portability and rethinking these technologies from a content perspective.  This mirrors Allscripts open platform strategy and was supported by some of the industry and policy analysts at the summit.  The tone in the room is that the movement toward open, interoperable IT systems in healthcare is inevitable and that the change will truly foster the improvements and innovation we all desire.

    Focus on Consumers

    The final key point covered in the summit was a significant focus on consumers in healthcare IT.  Many presenters cited the importance of a stronger focus on both patient- and person-centered approaches and tools — an expectation that is being driven by consumer software.  HIT has traditionally been considered B2B or Enterprise software, and that carries a focus on process, customization, and implementation more than on end-user experience.  Several speakers made the point that the old model cannot survive in the long-term. HIT vendors must focus more on end-user experience, where end-users include patients as well as providers.  As we begin to deliver tools to patients (a requirement of both Meaningful Use and the Accountable Care Organization model), this shift from B2B to B2B/C is going to become more pronounced.  We are going to need to have significant focus on the usability and user-experience of patients in these tools. 

    Time for a Pause?

    So let’s return to that headline question. The final wrap-up of the summit attempted to answer the question:  “What impact has policy had on usability?” At this point, I offered Allscripts perspective that Meaningful Use has had a fairly negative impact on usability due to the pace and volume of change required of vendors. EHR companies like Allscripts have invested enormous resources to satisfy fast-evolving Meaningful Use requirements in an extremely challenging time frame.  One of the common themes in all the comments at the summit was the need for a pause to allow everyone – vendors, clinicians, and other healthcare entities – to consolidate the efforts of Meaningful Use.  That was a strong close the summit and a message that the organizers said they intend the deliver to the decision makers within the government.

    But while there’s no question the pace of Meaningful Use is challenging, we need to be careful about taking a pause.  When a federal program pauses, it rarely gets restarted. And as difficult as the program is, there’s no doubt in my mind that it will ultimately contribute to the outcome we all want – higher quality care at lower cost.  Rather than a pause, what’s needed is a steady, thoughtful process.  As the regulatory process keeps rolling forward, it’s important to check on progress, challenges, and other status points along the way, and redirect as needed.

    That’s especially true when it comes to usability. Clearly, the pace of Meaningful Use has made it more challenging to focus on usability in the short term as much as we would like (most of my peers at the other vendors concur). But the real question is the program’s long-term impact on usability.  That is where Meaningful Use is likely to pay dividends by requiring interoperability, quality measures, clinical decision support, patient inclusion, etc. 

    Many of these capabilities are critical to improving long-term usability and will allow these systems to evolve in the way that we all know they must.

    I’m curious.  What’s your view of the pace of the Meaningful Use program? And how has it impacted the usability of solutions like the Electronic Health Record?

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