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    In defense of necessary clicks: The science behind usability

    September 1st, 2016

    If there’s one thing we know about EHRs, users hate clicks. And for good reason. Clicking and scrolling historically have represented extra time, effort and evidence of not understanding an efficient workflow. Click reduction is often cited as the best way to improve electronic health record (EHR) usability. Our gut instinct tells us that we should do everything we can to reduce clicks.

    Yes, unnecessary steps are annoying and should be removed. But we have to be careful that we don’t actually increase cognitive load, hinder decision making and reduce overall efficiency and satisfaction in our zeal to reduce clicks and scrolling. There is a great deal of research available that should guide the design, implementation and customization of EHR interfaces.

    In the evidence-based practice of medicine, scientific evidence should also guide Health IT usability decisions. Some of these known facts that come from a solid foundation of research results include:

    Processing fluency – When users encounter cognitive hurdles caused by poor EHR design, they are more likely to judge the task as more difficult and task performance suffers. So it is important to remove anything that interrupts processing fluency. For example, the date format “10/5/16” requires the user to translate the number 10 into October, whereas “Oct. 5, 2016” is faster for the user to process, and is more globally understandable. Removing these processing interruptions will increase overall satisfaction and performance

    Readability – The more “readable” text is, the better your comprehension rates will be. Studies have shown that sentence length, contrast, font size and color all play a role in how easily a reader will be able to understand information. Follow best practices, and the user is less likely to experience eye strain, miss important information or waste valuable time.

    Fear of emptiness – Also known as Horror Vaccui, is the idea that people have a natural urge to fill blank spaces. Ironically, the more we fill blank spaces with objects or information, the perceived value decreases.

    Cognitive tax – When two or more perceptual or cognitive processes are in conflict, it requires additional processing to resolve the conflict, and the additional time and effort have a negative impact on performance. Decision-making research shows us that not only can more information be more cognitively taxing, but it can also lead to suboptimal decisions.

    Data vs. Instinct – Which will win out in usability decisions?

    The industry recognizes we need to improve EHR usability. Decisions about design and usability should not be based on instincts or “gut feel.” Designers should follow specific guidelines that they all too often ignore in favor of other considerations. For example, using brand colors for text and background on a web page might fit visual branding standards, but it could create a readability issue if the colors don’t have a good contrast ratio.

    There are three main things we should do as an industry that will help advance usability:

    1) Believe the science. We rely on scientific evidence to guide clinical decisions, we should adhere to the same standards for usability. Rely on data to understand the tradeoffs with every decision. For example, we can get more information on a screen to remove clicks and scrolling, but reducing the font size to do it will make reading slower, more difficult, and more error-prone.

    2) Participate with and hold vendors accountable. EHR vendors need honest, consistent input. Work with them and point out trouble spots. Let them know when readability is compromised. Point out unnecessary clicks, but recognize that a narrow focus on clicks can mean exchanging one source of pain with another that could be worse for safety and satisfaction.

    3) Be open minded. Some new interactions may not feel right or familiar at first, but if it’s based on good data it will help improve efficiency, effectiveness and satisfaction. When they’re based on research and best practices for user-centered design, you will likely find that they improve your overall experience with related tasks.

    By embracing these principles, we can steer usability away from “gut feel” and make data-driven, evidence-based design decisions.

    Editor’s Note: For more examples and references, Allscripts clients can access Ross Teague’s “Science of Usability” presentation on ClientConnect. Two additional useful references include Universal Principles of Design by William Lidwell, Kritina Holden, and Jill Butler; and Universal Methods of Design by Bella Martin and Bruce Hannington.


    “Improve usability…but don’t change anything!”

    June 8th, 2016

    Organizations and users in the Health IT world desire products with better usability and efficiency, but they hesitate to embrace changes to familiar interfaces and interactions. Humans don’t like change for many reasons.

    In Health IT, changes to interaction models, layouts and workflows can mean retraining, which costs money and takes time away from work. There are also concerns that users will be less efficient using something different, or that it will reduce satisfaction.

    Many times what we are comfortable with is not what is best for us, even though we have adapted to it. Users may not realize the physical, mental and safety “costs” of sticking to what is most familiar.

    While familiarity associated with software is often related to steps in a workflow, it can also be familiarity to icons, colors and layouts. Users may not see how a change in colors can improve their experience with a product, but color can have a big impact on readability, distraction and cognitive load.

    As an example of how familiarity can get in the way of usability, one of our products used bright colors to highlight status on a display board. We found through analysis that a change in colors would have improved the readability and reduced the “cognitive tax” that users pay each time they interact with the display, but the consistent message from clients was “We’re familiar with it. Don’t change it.”

    Balancing usability with familiarity

    How we deal with these competing interests is important. At Allscripts, we try to address this familiarity-usability issue in a number of ways:

    1. Make sure that change is necessary. All changes should benefit our clients in some way.
    1. Follow a best-practice User-Centered Design (UCD) process. We base our designs on understanding the goals of our users, and measuring the product with users during development to make sure that the product continues to meet these goals.
    1. Don’t dismiss familiarity. Understanding our users and their experiences is an important part of our process. The design process benefits from knowing what tools, workflows and interaction models that are familiar to our users (inside and outside of a clinical environment).
    1. Clearly explain the ROI of making the change. We communicate the measurable benefits of learning a new process, retraining or a short-term loss of efficiency for the more important long-term gains of output, safety and satisfaction.

    Balancing usability with familiarity is an important aspect of any design effort. Familiarity is important, but it can’t get in the way of usability and improved performance. Our goal is to create products that support our clients’ needs for safety, efficiency and effectiveness. For solid improvements in these areas, the effort to change is worth it.

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    EHR design requires user input, early and often

    April 7th, 2016

    Adherence to user-centered design (UCD) best practices is key to improving electronic health record (EHR) usability. A recent white paper reviews UCD best practices, and how they help improve usability and patient safety.

    Unfortunately, many EHR vendors skip a crucial step in UCD: formative testing. In this phase, software designers test early versions of the technology with actual users. They’re not testing completed code or solutions ready for market, but rather prototypes, wireframes or even early sketches.

    Good formative testing is iterative, meaning designers must gather and address feedback from users several times before finalizing the software. To illustrate how the formative testing process works at Allscripts, here’s a recent example from our Allscripts Sunrise™ Ambulatory Care solution.

    Example: Formative testing for a new task module

    The Sunrise team conducted formative usability tests on a newly designed task module with six clinicians. The User Experience team held one-on-one, remote sessions with each participant lasting 60 minutes each. These sessions helped test a set of 10 specific measurable usability goals, such as “100% of users can view and acknowledge results.”

    During each session, the moderator asked the participant to complete a series of tasks on a prototype. For example, one task was to find prescription refill requests for a patient and another was to view tasks assigned to the user.

    The moderator observed how well participants were able to complete the task, recording reactions and recommendations for improvement. In this case, participants suggested using a different icon for the workflow manager that was more familiar and intuitive. The moderator then summarized the number of tasks completed and qualitative comments, and calculated a System Usability Score (SUS) from subjective user data.

    Results: Users rate interface as more enjoyable and intuitive

    Overall feedback on this prototype was positive. All physicians said they would like to use the new functionality, and they felt the workflow was better than the current functionality.

    All but one measurable usability goal met or exceeded expectations. On average, users rated the interface 49% more enjoyable, 40% more intuitive, 36% better at giving the right information at the right time, and 70% “newer” and “fresher” looking than the current application. Users also averaged a 97% task completion rate and rated the application as very usable with a System Usability Score (SUS) of 87.

    What’s next?

    Learning that we didn’t meet one of the usability goals lets us go back and address the issue before the product launches. There are minor adjustments we can make to the Sunrise task module to make it even better. Allscripts will refine the design based on these findings and continue testing with Sunrise users.

    The best way to keep users at the center of EHR design is to involve them early and often in the process. Involving them in a meaningful way will continue to improve usability.


    Why EHR usability has fallen short

    March 7th, 2016

    A recent article said that electronic health record (EHR) usability is poor because clinicians are not the ones who are designing the products:

    “Physicians and other clinician users of electronic health record systems commonly rate the products low on a usability scale, in large part because non-clinicians do the bulk of the work designing them.”

    But does usability really suffer because non-clinicians are designing Health IT solutions? When we look at other industries, we don’t see end users primarily responsible for the design of successful products. For example, accountants don’t design banking technology, and writers aren’t developing word-processing software.

    Why do products in other industries seem to be more reflective of users’ needs? For EHR usability to improve, do clinicians have to create and design the products, or is there another more impactful way for them to be involved?

    I believe usability lags in Health IT because EHR vendors have not applied rigorous user-centered design (UCD) principles. It’s not that clinicians haven’t been involved, they just haven’t been involved in a meaningful way.

    5 design shortcuts that can stunt EHR usability

    End users must be involved early and often throughout the design process. Some EHR vendors take short cuts, which leads to poor design that negatively affects usability. These vendors call it user-centered design, but they make these common mistakes:

    1) Counting demos as feedback sessions

    Let’s say an EHR vendor is presenting a new product concept in front of an audience to collect design input and asks at the end of the session, “Any feedback?” This request for input doesn’t go deep enough to provide meaningful input to the solution.

    Fix: Preview the solution in one-on-one sessions with actual users performing relevant tasks.

    2) Asking too late

    When an EHR vendor only collects user input for a new feature or solution just prior to launch, it’s too late for the clinician to give feedback that can affect product design. The product is about to release, and it would be too costly to change it.

    Fix: Involve clinicians earlier in the process with formative testing using sketches, wireframes and prototypes.

    3) Giving unrelated tasks

    Using testing tasks that do not directly relate to patient safety and the specific end-to-end goals of the user do not adequately evaluate the product. Test results aren’t as valuable.

    Fix: Rigorously assess tasks before testing them with users. Involve clinicians in designing the tasks to make sure they are clinically relevant.

    4) Listening to (only) the squeaky wheel

    EHRs should not be designed by the loudest user.  Don’t overgeneralize one person’s experience or feedback when designing solutions.

    Fix: Consider each user’s feedback as a single data point in context with other testing results. Use data to explain to your customers why product direction highlights efficiency, reduction of cognitive load and patient safety, particularly when you make a design decision that is not what they suggested.

    5) Testing with the right users

    All of these other items assume that the feedback is coming from people who are the actual end users of the solution. Too often, designers only collect feedback from the purchaser, who may not have the same background and goals as your intended users.

    Fix: Collect usability data from the people that will be using the product for its intended purpose. It’s okay to collect feedback from others (e.g., purchasing, trainers, IT), too, but let user input guide and have the most influence.

    Rigorous UCD processes improve EHR usability. Aligning with best practices is the right thing to do for many reasons, the most important for EHRs is patient safety. It also serves as the most effective and efficient way for clinicians to have an impact on the design of a product.

    As Health IT catches up with other industries on the application of UCD, clinicians will be appropriately involved and users of Health IT will feel like the products were designed by someone like them.

    To learn more about how Allscripts applies UCD principles, download this free white paper.


    10 things acute care nurses need to succeed

    October 24th, 2013

    Allscripts User Experience team recently conducted a field study of 100 nurses at 10 hospitals. We wanted to better understand what problems and hindrances acute care nurses experienced and how technology can help nurses deliver better patient care.

    The findings will help shape our solution development efforts, particularly in mobility. We shadowed nurses in a variety of departments and watched their interactions with other nurses, techs, physicians and patients, as well as all of the tools and technologies they use during their shift.

    Acute care nurses have unique challenges

    Our research shows that nurses have very different problems than physicians do. They are constantly being interrupted while trying to maintain and manage their conversations with other clinicians and patients.

    Acute Care Nurses often still use paper, entering data into Allscripts Sunrise much later.

    Most acute care nurses are documenting vitals and patient information twice, often using paper even when computer entry is available.

    One finding we saw repeated in all hospitals was the nurse reliance on paper and the creation of paper “brains” to keep track of their tasks and for temporary note taking.

    I make this hourly chart every morning [on paper], because I like to know what I need to do each hour of my shift. This ‘brain’, as I call it, is my safety net.”

    They are recording tasks to complete, patient vitals, medications and other information on paper. They add the data into Sunrise later – often many hours later. Unfortunately, their to-do lists get out of date very quickly.


    Acute care nurses are clear about what can help

    Our team developed 10 themes that illustrate the most significant challenges acute care nurses face. These are also the most promising areas for development efforts. Put into the voice of a nurse, solution needs include:

    1.    Don’t make me do the same thing multiple times.

    2.    Combine patient information to give me only what I need, when I need it.

    3.    Give a clear to-do list – that shows completed tasks — for each patient.

    4.    Enable me to document quick tasks at the time of completion.

    5.    Let me know when I have something to do wherever I am.

    6.    Remind me what I was doing when I get interrupted (or when I  multi-task).

    7.    Help me to communicate with less disruption with the right people.

    8.    Give peace of mind that my part of the task workflow is complete.

    9.    Show the physical location of my patients (and staff relevant to their care).

    10. Help me to develop and maintain the patient-provider relationship.

    A few more observations about acute care nurses

    Primary communication is still talking on the phone or in person. And nurses still rely on paper; It’s fast, easy and unrestricted.

    Even though nurses often rely on paper, don’t underestimate their technology savvy. They are very capable users. Any tool or solution just has to be flexible enough to match their unpredictable workflow.

    Nurses are never empty-handed. It’s up to us as healthcare IT providers to make products worth carrying around.

    Did we get it right?

    Understanding our users is fundamental for delivering well-designed products that integrate into their workflow.  As we develop new products for nurses, we will use the tenets above to ensure we create meaningful solutions that enhance their experience with our products.

    Do you see these same fundamental needs in your organization? Which ones have the most impact on your being able to provide the best patient care possible? Have we missed any important needs? Please share your thoughts in the comments below.


    New Note reflects user-centered design

    March 20th, 2013

    We are working to improve our clinical documentation tool, Note. Caregivers use it to record encounters with patients, so it’s important that the tool is efficient and effective.

    There’s always room for improvement. We’re paying close attention to how clinicians currently use and want to use the tool to help shape the next version, following a user-centered design (UCD) process.

    The rise of user-centered design in Health IT

    It has been around a while, but UCD has received more attention lately in the Electronic Health Record (EHR) industry. Meaningful Use Stage 2 requires suppliers to follow a UCD process to develop certain types of products.

    UCD encourages engaging with users early and often. It emphasizes understanding their goals, requirements, context of use, and evaluating designs with users throughout development. UCD can help lead to better efficiency, safety and overall satisfaction.

    We’re using UCD and working closely with clinicians to make sure we get the new version of Note right.

    Engaging with clinicians at every stage of development

    We incorporated UCD from the beginning of the development process for the new Note. Our team watched clinicians using their noting tools in their environments using ethnographic research techniques, and we conducted numerous interviews. This information helps us determine which features and interactions will be the most valuable.

    EHRs live inside a dynamic, complex environment. Our research efforts also weighed technology, regulatory, cultural and financial factors (to name a few). As part of our UCD process, we identified specific performance metrics related to efficiency and safety that we use as design requirements. We’ll ultimately evaluate the product against these metrics, too.

    Moving into the design phase, we built around existing patterns that had been tested by users in other products. We met human factors guidelines for intuitiveness, efficiency and safety.

    Throughout the entire design process, we kept in close contact with users. We shared screen shots, held reviews with user groups, and had 1-on-1 sessions where we watched clinicians perform typical tasks with low- and high-fidelity prototypes.

    What users can expect from the updated Note

    We’re improving the new Note in three main areas. It will offer:

    1. Better user experiences – The tool will encourage structured data entry, but it won’t make users feel boxed in. It will offer structured entry, free text and voice-to-text options in all sections. It will be easy to understand, following “WYSIWIG” principles (“What You See Is What You Get”), and enable personalization, such as favorites and default settings options.

    2. A single web and mobility solution – The tool enables a single experience across solutions and devices. Users can input information using voice-to-text or touch.

    3. Easier administrative maintenance – It will be easier to create content, and it will be easier to share it. Better, more accessible content helps support analytics and clinical decision making.

    Stay tuned for information on the updated Note, which we expect to be generally available in the fourth quarter of 2013.

    In the spirit of user-centered design, we’d love to hear your thoughts on what would most positively impact your day-to-day noting experience.