Digitizing the physician office: Usable software

By Mike Martineau

Around the turn of the century (that phrase still sounds odd to me, I keep thinking 1900, not 2000) I worked for a major Canadian systems integration company. One of the groups with whom I worked quite closely was the company’s usability team. I witnessed firsthand the power of incorporating usability into the software design process and the extent to which end-users willingly embraced the system produced using this approach.

While researching material for my book on digitizing the physician office, I have heard numerous complaints over the past few months about the usability (or, more specifically, the lack thereof) of many EMR systems currently on the market. Hence, I was intrigued to read a summary of a recent Technology for Doctors article (“How I learned to stop worrying and love my EMR,”) on FierceEMR. Although the Technology for Doctors article did not mention usability explicitly, the U.S. summary concluded:

“So perhaps the lesson here isn’t that the U.S. health system is a mess – which it is –  but that EMRs must be user-friendly and work the way doctors work.”

What is usability? According to a background paper produced by the Healthcare Information and Management Systems Society’s (HIMSS) EHR Usability Task Force, usability is “the effectiveness, efficiency and satisfaction with which specific users can achieve a specific set of tasks in a particular environment”.

Usability is not a functional requirement and is therefore often not addressed in the requirements specifications against which EMR software is certified in many jurisdictions. Indeed, a 28 June 2010 blog post by Dr. Glenn Laffel on EHRBloggers notes that the meaningful use criteria in the United States against which EMR software in that country will be certified “do not address the matter at all” and that “Many cumbersome, poorly designed EMRs will get certified.”

The HIMSS EHR Usability Task Force contends that:
“It is particularly challenging to develop excellent usability in EMR systems. There is a wide range of complex information needs, which vary from setting to setting, among different administrative, financial and clinician groups, and from task to task within a group.”

The same task force identified nine usability principles that must considered when evaluating EMR usability. Based on my previous usability experience, a review of literature related to EMR usability, and conversations with EMR users, I’d like to highlight what I believe is one of the most difficult principles to address when designing EMR software – minimizing cognitive load.

As designers of airplane cockpits have learned over the years, it is possible to present information in such a way as to overload a user already dealing with competing demands for their attention and impair their ability to make the right decision. In the case of physicians, cognitive overload can negatively impact patient safety. Good user interface design presents information in such a way as to not only minimize cognitive load but to also assist with task performance and decision-making.

Minimizing cognitive load is perhaps one of the greatest challenges faced by EMR designers. I suspect that difficulties vendors face addressing this challenge may be one of the reasons that physicians have been reluctant to enthusiastically embrace EMRs. Dr. Heather Leslie, an Australian physician who blogs and tweets on various topics related to electronic capture and display of health information, offers perhaps the most eloquent summary of this challenge:

“Clinicians record their findings and conclusions remarkably efficiently on paper, recording the contextual variations succinctly and in a way that other clinicians can understand. Getting computers to do the same thing – to enable clinicians to record simply in the normal circumstances, but be able to cope with the complexity and detail where it is critically needed – is not a trivial task. Ensuring that a user interface reflects a clinician’s work flow and captures the evolving requirements in a clinical consultation is extremely complex.”

Usability is one of the topics that I am exploring for my book on digitizing an office. As part of my research activities, I am eager to speak with physicians and medical office staff who have or are about to implement an electronic medical record system. Please contact me at michael.martineau@avenant.ca to arrange an interview for my book. Also, please check out my views on other facets of healthcare IT on my blog, eHealthMusings.ca

Posted July 22, 2010