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Physician input is vital for good Health IT design. The only way we can continue to improve adoption, usability – and ultimately patient safety – is to engage users early, often and through all stages of software design.
Involving users is one of the guiding principles of Allscripts’ user-centered design (UCD) process, the subject of a recent white paper. When building new products or improving existing solutions, we follow those best practices.
Formative testing catches mistakes before it’s too late
All too often, users don’t get a chance to weigh in until Health IT solutions are about to be released. But we take great care to conduct formative testing for our new features and solutions. This type of testing occurs with early versions of solutions, such as wireframes, sketches or prototypes.
Designers hold one-on-one sessions with actual users. They provide real-world scenarios or tasks and observe actual users as they interact with the product. Designers carefully record observations and suggestions for improvement. A great example is testing the Allscripts TouchWorks® EHR immunization feature with physicians.
Enabling physicians to complete navigation tasks in 8 seconds or less
At the end of 2015, Allscripts released a new version of TouchWorks EHR. The prior two releases focused on meeting government regulations, such as Meaningful Use Stage 2 and Electronic Prescribing of Controlled Substances (EPCS). In this version, we were able to more fully address usability issues.
For example, we conducted formative testing with physicians about the new immunization feature. One early round of testing involved physicians who completed a series of five tasks, such as identifying the number of doses given.
The goal was to enable users to complete each task in less than eight seconds and achieve a Subjective Usability Score (SUS) rating of 85 or greater. Users were able to complete tasks within the target time and the average SUS rating was 97.5.
However, the testing also identified some confusion with a specific notification that led to re-wording the alert for clarity. This feedback is extremely valuable in our efforts to continuously improve.
Making strides toward better usability
Formative testing is where we make the greatest strides with usability, not demos. We’ve found that about 40% of all usability issues related to patient safety are caught during formative testing, and this early feedback enables our team to correct these issues before releasing the product.
To learn more about our user-centered design practices, download this free white paper.
As one of the clinical architects of Allscripts TouchWorks® EHR, I work hand in hand with our functional architect, product owners and user-centered design (UCD) experts. We work as a team on new designs to make sure we’re using best practices to improve usability.
We developed the following guiding principles as a checklist to help us better focus our product development on what users need:
1. Let users do their work when and where they discover it needs to be done.
Reduce the amount of unnecessary clicks to complete a workflow. Design navigation and workspaces to enable users to perform a wide variety of tasks, while tailoring them for the most frequently performed actions. Where possible, free cognitive resources with automation.
2. Acknowledge chaos.
Consider users who perform tasks in chaotic work environments, where interruptions are expected. Make it easy for users to resume suspended tasks. Expecting chaos has driven feature improvements in TouchWorks EHR 15.1.
3. Every action needs a clear recovery path.
Mistakes happen. Users must have an option to correct mistakes. Error warnings and notifications must clearly explain what is wrong and give the user a simple solution to retract and fix it.
4. When everything is important, nothing is.
Highlight information users will most likely need for the task at hand. Only use color with other cues to provide emphasis. Build displays to adapt to the available screen size.
5. Don’t make a user do something to know if it was worth doing.
Always provide the user with enough status information to decide what they need to do or where they need to go next. Status information must be trustworthy (perceived by users as up to date and accurate).
6. Track it so you can improve it.
Record how people use our product, making it possible to include actual usage data in enhancement design decisions.
7. Balance personalization options with best practices in usability.
While it makes sense to tailor the software to fit the user, each individual’s preference may not optimize usability. Enable configuration of the system, but place limits in line with usability best practices.
8. If a feature can’t be set up and maintained it can’t be used.
If the admin cannot configure and maintain the feature, it may never get “turned on” and the user will never get a chance to use it.
9. Reduce the configuration burden.
Don’t give every possible configuration option, but enable only when necessary to reflect a business rule. Consider the cost in set up, maintenance, testing and how many users need those options.
10. Make interactions consistent.
Users should be able to predict the behavior they are going to experience, once they learn the patterns of the system.
We created this checklist to enable continuous improvement. It’s based on real-world experience over the long evolution of electronic health records (EHRs). We apply it consistently to our development efforts so we support how users want to work and help them achieve their goals.
The Mississippi Delta, a region in the American South along the Mississippi River, faces higher rates of diabetes than the rest of the United States. In fact, the Center for Disease Control has identified the area as part of “The Diabetes Belt,” where 11.7% of people have been diagnosed with diabetes, compared to outside the belt with only 8.5% of the population.
The Delta Health Alliance (Stoneville, Mississippi, U.S.A.) shared how it is using Allscripts solutions to manage diabetes care for better clinical and financial outcomes in a recent case study and video:
A lack of physicians in the Mississippi River Delta region can limit patients’ access to health care. Providers need solutions that can help identify and improve communication with at-risk patients. To help meet demand for proven technology, the Delta Health Alliance is a collaboration of 60 Federally Qualified Health Center, rural health and private-practice physicians focused on researching the best methods.
“We have doctors who are very passionate about treating diabetes in the Delta,” Assistant Vice President of Information Technology and Chief Information Officer Daniel Thomas said. “Through the Beacon project and using Allscripts solutions, doctors are able to give the same level and quality of care to these patients that they would receive in major metropolitan areas.”
With a three-year federal Beacon grant from the ONC, Delta Health Alliance implemented several programs in 17 rural counties to improve care for diabetic patients. Working through the Mississippi Health Information Network, the state’s health information exchange (HIE), Delta Health Alliance implemented various programs throughout four hospitals and 37 clinical practices throughout the Delta.
Care Guides enable enhanced disease monitoring
Delta Health Alliance incorporated best practices and national care standards into Allscripts TouchWorks® EHR and developed Care Guides. These tools help clinicians by alerting them to evidence-based tests, medications, education and other requirements for specific patients and diagnoses.
The Beacon grant provided funding to implement the diabetes Care Guide with specific reminders for the types of tests that diabetic patients require more frequently, including glucose screenings, hemoglobin A1c (HbA1c) tests, foot examinations and eye screenings. Implementing these Care Guides in 29 targeted Delta clinics, clinicians used them during 31,000 examinations.
“Using TouchWorks and the Care Guides through our Beacon project, we were able to show a statistically significant decrease in HbA1c values for our participating patients,” Thomas said. “We lowered obesity and [Body Mass Index], and we actually showed the ability to control blood pressure. It’s all documented in the [TouchWorks] EHR.”
To learn more about how Delta Health Alliance is helping to improve diabetes care in the Delta, download a free case study. If you’re attending AMGA Annual Conference (Orlando, Florida, U.S.A.) this week, stop by Allscripts Booth 821.
Editor’s Note: The Delta Health Alliance gratefully acknowledges support of this project through the Office of National Coordinator Grant Number 90BC0004-01.
Have you noticed more advertisements from your local emergency and urgent care centers, talking about shorter wait times? It’s because healthcare organizations recognize that wait times play a significant part in satisfaction rates for patients and clinicians.
Monitoring a patient’s experience throughout the visit can be challenging, especially if an organization must manage resources across multiple sites. Sharp Rees-Stealy (San Diego, California, U.S.A.) uses Allscripts TouchWorks® EHR and the Patient Tracking Board to improve the patient’s experience across its five urgent care settings.
Improving patient experience in Sharp Rees-Stealy urgent care settings
Through a quality-improvement initiative featured in a recent case study, the organization focused on three areas: intake, radiology and discharge. By streamlining these processes, Sharp Rees-Stealy has become more efficient and significantly increased patient satisfaction scores.
The solution provides greater visibility as patients move through urgent care departments. “Day to day, the Patient Tracking Board helps staff manage patient flow,” Urgent Care Supervisor Roxanne Norton, BSN, CEN said. “We can use milestones to see where patients are in their stay, the time that they’ve been in the department, notifications when orders are up – and it’s all minute by minute.”
Sharp Rees-Stealy met its quality improvement targets for urgent care, by reducing wait times and improving patient satisfaction. “Patients notice a difference, because it takes less time to get them into an exam room and seen by a physician,” Manager of Operations Cheri Pope said.
Top 3 advantages of using the Patient Tracking Board
As an urgent care physician, I see three main advantages to the Patient Tracking Board, for which the new version 16.1 is now generally available:
1) Enables clinicians to better prioritize by acuity
For departments that offer walk-in, same-day appointments, clinicians need a way to deal with acuity. You take patients in the order that they arrive, but a man over age 50 with chest pain needs to be seen urgently. A schedule module doesn’t have the same capability to bump people up or down based on the severity of their symptoms.
2) Speeds results for more acutely ill patients
Patients with complex conditions may be receiving multiple services – such as medications, breathing treatments, x-rays – and those results need to be available immediately. A tracking board order status lest you see a patient’s progress, and all the moving pieces, in a new way. Even though tracking boards are often thought of for urgent care and emergency departments, this capability could extend to other complex, team-based care settings. For example, I could see applications for chronic disease management programs or cancer centers coordinating a chemotherapy regimen for patients.
3) Improves visibility for care team members
Urgent care settings often use a team approach to care, which requires significant coordination among caregivers. The Patient Tracking Board enables clinicians to see who has been involved with each patient’s care and what has been done to date.
This version offers alerts, which helps clinicians keep track of what patients need and when, such as a clinical alert to repeat a blood pressure reading after a certain amount of time. Clinicians can temporarily delay the alerts, so that they can deal with frequent and necessary interruptions in real-world emergency and urgent care settings.
Sharp Rees-Stealy was instrumental in developing a Patient Tracking Board that would work across multiple sites to improve the patient’s urgent care experience. To learn more about this story, download a free case study.
As a physician who practices in an urgent care setting, I know what it’s like to be interrupted all day, every day, while trying to use an electronic health record (EHR). To have to leave one screen to deal with an urgent message or lab result, then try to navigate back to where I was to finish my documentation – workflow challenges are abundant.
At the end of most days, I have to spend another hour to catch up on documentation. I understand why physicians avoid steps that take three or four extra clicks, because over the course of a day with 30 patient visits, those clicks add up. Worst of all, poor EHR usability is more than frustrating; it is a patient safety issue.
Thinking like our users
Like most clinicians, I’m concerned about EHR usability. I’m part of a team that’s working to continuously improve Allscripts TouchWorks® EHR. Our team – including clinicians, user-experience designers, product owners and functional experts – works closely with our clients through user groups and our provider advisory board.
We adhere to best practices for user-centered design (UCD), a process to improve our software and make it easier to use. In fact, TouchWorks EHR was one of only two solutions to earn a perfect score in an American Medical Association (AMA) and MedStar Health evaluation of alignment with best practices for user-centered design and testing.
One of the reasons we are proud of our improved UCD processes is that we do both formative and summative testing of new software releases. Some vendors rely on summative testing, which is the kind you do at the very end to gauge how well users understand the software. But if these tests identify a problem, it’s often too late or costly to fix it.
We conduct formative testing with our users in a one-on-one meeting, using prototype solutions, and throughout the development processes, as ideas take shape. We did a lot of formative testing for the newest release of TouchWorks EHR, 15.1. Formative testing with users identified design flaws and gave us the opportunity to alter the design for a better product
As a clinician, I help ensure that the scenarios we test are clinically realistic and relevant, to maintain our credibility with clinicians. For example, we could ask clinicians to test scenarios with patients who have two diagnoses and three medications. But the reality is, with the prevalence of chronic diseases, clinicians often have to treat patients with multiple diagnoses and sometimes dozens of medications. Testing with real-world scenarios leads to clinically sound and relevant design choices.
Reducing interruptions to the user’s workflow
Many of our recent releases have had a large regulatory component, but this time we were able to focus on a lot of usability improvements. We’re excited to address some of our clients’ most frequent enhancement requests that will help users be more efficient when using the EHR, for example:
1) More efficient response options for alerts – Let’s say I get a warning message about allergies while documenting a patient visit. Instead of having to close the message and find the allergy history section, I can now update allergies directly from the message and continue my documentation. There are similar options for other alerts, such as duplicate problems.
2) Faster documentation with text macros – Users can now design a block of text and trigger it in the application with a simple text string or typing the name of a macro. For example, a nurse could use three or four keystrokes to insert a common set of instructions or contact information.
3) Saving time with in-line chart viewer – Previously, chart notes and result documents would open in a new window making it difficult to view these items and your current documentation. Now, users can see the chart and document while the chart is open, which is a huge time-saver when verifying and results and creating visit notes.
Of course, there are many more features in TouchWorks EHR 15.1. We’re consistently working to make it easier for users to navigate, sort and read information to ultimately enable better care – one patient at a time. Because we’ve designed these workflows expecting chaos that the real world brings, I believe our tools are going to be even more indispensable to clinicians. Contact us to learn more.