EMR Usability

The HIMSS EMR Usability Task Force thoroughly reviewed this topic and published an excellent review of usability this past June. I highly recommend the article to anyone with interest in this area. I will not discuss the concepts involved with the same degree of detail that they did. This post is merely meant to be an introduction.

EMR usability is a subject that is being discussed ever more frequently. One reason is that the lack of usability has been a major barrier preventing more widespread adoption of EMRs by clinicians. Usability affects the amount of effort needed to implement EMRs, clinician satisfaction, practice efficiency, and patient safety. I have selected a few usability issues to discuss here.

Ease of Learning. Medical professionals do not have spare time to devote to learning complicated software packages. The design of EMR software should be intuitive to minimize the amount of time needed to train clinicians adequately so they can perform their day-to-day medical record activities. The pages presented to the user should be consistent in appearance as one navigates through different sections. Software that behaves like other programs the user has experience with is also easier to learn. One should not have to refer to a user's manual or online help to accomplish common functions and activities.

Patient Safety. EMRs should be designed so that they are safe to use. New types of errors caused either by the software itself or by operator mistakes that could harm patients must be avoided. Actually, the goal is that patients should be safer when electronic records are used than when traditional record keeping on paper is utilized.

Human Factors Engineering. This is the scientific study of how humans interact with technology and how the experience can be optimized for the user. Objective techniques are used to evaluate the human-machine interaction. Benchmarks are established first and then a rational approach is used to improve software and hardware through use of validated metrics. Best practices are promulgated to help improve the entire industry. Users and designers should work in collaboration. Many have the sense that this has not been done very often with health IT. Some of the topic headings that follow are subtopics of human factors engineering.

Speed. Clinicians want technology that improves productivity, not something that slows them down. Many clinicians who received their training using paper-based medical records have developed workflows that are hard to adapt to the electronic environment. Many factors affect speed that may include: network infrastructure design, number of users on the network, use of wireless devices, software that require navigation through multiple pages to reach the desired site, and the need to enter data by typing on a keyboard.

User Interface.
Color: Designers need to be very careful with the use of color. A percentage of the population is colorblind so they might not recognize the information the use of color was meant to convey. Also, although there may be some general agreement about the significance of specific colors, some users may hold alternate understanding about the meaning of colors. The significance of colors is linked strongly with cultural background. When color is used there should also be another method used to convey significance (e.g. bolding, caps, underlining, etc.)
Font: Generally, sans serif fonts are considered easier to read on a computer monitor than fonts with serifs. The user should have the means to adjust font size to compensate for reduced visual acuity. This has important implications for older users, user distance from the screen, and smaller screens.
Navigation: Whenever possible, all relevant information to the activity being performed should be presented on one screen. Users should not be expected to recall information from one screen when they must work on another. All effort should be made to minimize the number of mouse clicks needed to do work. Shifting between the mouse and keyboard slows users down. Many clinicians do not like to scroll. Finally, it should be easy to undo a mistake. "Hover-over" features can enhance to user experience when deeper drilling into data is desired. This feature must not be overdone because that can also be frustrating.
Presenting expected data: The best software designs have baked-in logic and algorithms that anticipate the needs of clinicians. For example, lab results of commonly associated tasks are automatically presented to the user without prompting.

In the future, I expect that vendors will devote more resources to human factors engineering in their products. I also think that we can reasonably expect that usability will be an area that is tested objectively as new criteria are developed for EMR certification. Improving usability of EMR software should aid the effort to expand EMR adoption by clinicians and hospitals in the US.

Online Graduate Degrees
My Experience

I have often been asked what it was like obtaining my masters degree in medical informatics on-, line through Northwestern University. I have prepared a PowerPoint presentation that summarizes my experiences. I have reformatted the presentation for this post. I thought this might help others considering applying for an online degree program.

I was in the third group of students accepted into the online program at Northwestern University. The on campus program had been running for quite some time. I am sure the program will evolve as it becomes more mature. I think they got most of it right the first time around though.

My Distance Learning Experience
Masters of Medical Informatics at Northwestern University
School of Continuing Studies

What is Distance Learning?
•Virtual Educational Institution
–No brick and mortar centerpiece
–Timing of classes
•Synchronous
•Asynchronous
–Rarely meet or see classmates/instructors
–Work with others across multiple time zones
–Most students have a "real" job

Comparison to University
•Similarities
–Homework
–Tests
–Grades
–Library resources
–Lectures
•Differences
–Attend class online
–Emphasis on collaborative projects
–Difficulty establishing relationships
•To the school
•To instructors
•To classmates

Benefits
•Work full-time or care for family and still go to school
•Attend a school that you otherwise might not have access to
•Often employers pay part or all of fees
•Don't have to dress to go to class

Masters in Medical Informatics
Curriculum at Northwestern University-
11 classes required
•Prerequisites-for those with a clinical background
–Networking and Telecommunications
–Data bases
•Core classes for everyone
–Technical
•Interoperability
•Decision support
•Statistics
•Introduction to medical informatics7
Curriculum cont.
–Business aspects
•Technology evaluation, acquisition, contracting
•Hospital operations
–Other
•Leadership, organizational behavior, influence techniques
•Legal issues, social issues, ethics
•Capstone class

What else could have been covered?
•Project management
•Data warehouse techniques
•Influencing government policy
•Government and private grants process

Course Instructors
•Selected regular full-time Northwestern University faculty members
•Other faculty-subject matter experts
•Guest lecturers

Curriculum at Northwestern Univ.
Synchronous sessions
•1 ½to 2 hours a week
–PowerPoint lectures by instructor
–Class discussion
–Student presentations
–Guest lecturers
–Live class polls

Asynchronous Interactions
•Assignments
•Class resources
–Recorded class sessions
–Reprints
–Library access-often to full text articles
•Discussion board
–Directed
–Spontaneous

Additional Teaching Aids
•Pre-recorded WebEx instructional sessions
•Required and optional class textbooks
•Video demonstrations
•Harvard Business School cases

Group Projects
•Collaborative effort required in almost every class
•Group dynamics
•Collaboration technologies
•Deliverables
–Group Paper
–PowerPoint Presentation
•Group grading
•Peer evaluations

Time Commitment
•Class-1 ½to 2 hours a week
•Homework/Reading-10 to 20 hours a week
•Group meetings-1 to 2 hours weekly
•Classes were on quarter basis ≈11 weeks in duration year round
•Breaks between quarters were 2 to 4 weeks

Student Performance Evaluation
•Grading-A, B, C, etc.
–Homework
–Group projects
–Presentations/Papers
–Proctored exams
•Midterm
•Final
–Peer evaluations

Technology Challenges
•Synchronous sessions
–WebEx
–Adobe Connect Pro
•Collaboration
–Group meetings
–Managing group documents
•Dropbox
•Googlegroups
•Multiple software programs needed for various classes
–Drawing-Visio
–Data base management
•Oracle/SQL
•Access
–Decision support-TreeAge
–Web page design
–Reference management-EndNote
–Outlining-Mindmapper
–Statistical package

Value provided by the Program
•Broad exposure to field of study
•Self-directed learning opportunities
•Contacts
•Challenge of group collaboration
•Valuable credential, especially for one with little practical experience in the field
•Time for reflection
•Portfolio of work

Curriculum Challenges
•Adequate subject matter coverage
•Who develops
–Program directors
–Instructors
•Certification of program

Final Thoughts
•You get out of the program what you put in
•Not for everyone
•Expensive if you pay your own way
•Requires commitment, self-discipline, patience, hard work

EMR Certification Revisited

The Office of the National Coordinator for Health IT (ONC) continues its work on a Notice of Proposed Rule Making (NPRM) on EMR certification that is expected to be released by the end of next month. Numerous stakeholders are anxiously awaiting this information. The process for EMR certification was set on a course for a major revision after publication of the February 2009 ARRA legislation. The Certification Commission for Health Information Technology (CCHIT) was the only government recognized certification agency prior to ARRA. Since July, comments from the National Coordinator, David Blumenthal, and his staff indicate there will probably be more than one federally recognized certification body in the future. This is an extremely important topic because use of a certified EMR will be one of the major requirements for Meaningful Use that will enable providers to qualify for incentives for EMR adoption and use after 2011.

Coming in the middle of the uncertainty about certification, the Chairman of CCHIT, Dr. Mark Leavitt, announced his retirement effective March 2010. One can ponder the reasons for this timing. There have been six years of demanding work in previously unexplored territory. Dr. Leavitt should be proud of his accomplishments. The success of CCHIT is reflected in the approximately 85% of EMR systems that have voluntarily certified, without a government mandate. I wish him well in his future pursuits. Perhaps he has achieved most or all of his personal goals that were established during the initiation of CCHIT. But I think there may be other reasons.

Government plans will axe at least fifty percent of CCHIT's mission and work output. Previously, CCHIT as an organization had two arms. Over 200 volunteers organized in a number of workgroups have developed the criteria for EMR certification and they have developed test scripts for testing EMR systems to ensure the criteria are met. The Department of Health and Human Services and the National Institute of Standards and Technology will take over these duties in the future. The second arm has consisted of jurors, representing a cross section of organizations, who perform the actual testing. No overlap of membership in the two arms is allowed to avoid conflicts of interest. It now appears that the ONC will encourage competition for the roles compliance testing and certification of EMRs. These decisions challenge both arms of the CCHIT purpose. The government's stance must have been especially disappointing for the Chairman of CCHIT who has worked tirelessly for the past six years.

There are those who have challenged the approximately 30% vendor representation on CCHIT workgroups. The vendors represent a wide cross section of the vendor community. Their representatives provide invaluable insight about the capabilities and experience from the vendor perspective. This does not constitute vendor bias. In fact, it probably has just the opposite effect because work group members must function in a collaborative environment. We should ask: will the ONC will have the resources to match the intellectual output of the 200 plus volunteer CCHIT work group members when it develops the future certification criteria and test scripts? Furthermore, there should be concern among vendors and purchasers of EMR systems about how consistency will be guaranteed when multiple organizations are involved in certifying systems. Finally, recognize that it took CCHIT a few years to develop the organization and to recruit participants for its certification effort. Although the rules have not yet been published, there can be little doubt that the mandates for Meaningful Use will require that any new certification organizations be operational and ready to test no later than mid-2010 for the 2011 criteria. To say the least, this will be a very challenging timeline.

For another viewpoint, see: http://geekdoctor.blogspot.com/2009/11/certification-verses-meaningful-use.html

Consumer Preferences

The Office of the National Coordinator for Health Information Technology released a draft document for public comment on October 5th (Draft Consumer Preferences Requirements Document.) Some of the concepts brought up by that document are the subject of this post. The HITSP Consumer Preferences Tiger Team spent a considerable amount of time reviewing the document and formulating comments earlier this month. I'm sure a lot more will be said in the future. Expect the issue of Consumer Preferences to be addressed by both the HIT Policy and HIT Standards Committees. Eventually, multiple stakeholders must contribute to a strategic framework to address this topic from the health IT perspective.

The first thing to recognize is that the implementation of consumer preferences will involve policy issues as well as technological capabilities. Conflicting federal, state, and local rules and regulations cloud the related policy considerations. Trying to harmonize these disparate approaches can be a real headache. Also, under HIPAA state laws take precedence over federal regulations, if they are stricter. With sharing of health information projected to occur across multiple state boundaries in the near future, lawmakers may need to consider instituting overarching federal rules. The reason is that when policies differ significantly from one jurisdiction to another it is impossible to assure consumers that their preferences will be honored. This significantly erodes consumer trust. We all recognize that trust is essential to the stewardship of confidential personal health information. The policy challenge here will involve assertion of at least a minimal set of policies that will ensure enforcement of consumer choices from one jurisdiction to another. The technical challenge will be the need to tag discrete data elements within declared consumer preferences and ensure that the linkage remains intact as data flows between the various systems that may access that data. Mechanisms will need to be developed to reconcile different versions of a consumer's preferences so that only the most up-to-date are utilized.

A dictionary of data elements will also be needed with standard terms or at least enough information to allow mapping of data types/content between organizations. It is amazing how many terms can be used to classify consumer preferences. For example, there are various shades of meaning between the common words-consent, informed consent, authorization, preference, directive, consent for information release, etc.

There are other issues to resolve. Among those that might be included are: authentication of users, authorization for information access based on location of user, user role, context of information use, timing of information access, and more. There will be different rules for clinician access, administrative uses, health care operations, and secondary uses including research, quality reporting, and possible commercial uses of information by third parties. The latter is an especially sensitive issue for consumers. A closely related area is the sequestration of information in health records. Consumers want to control the release of their personal health information concerning sensitive issues such as alcohol abuse, HIV/AIDS status, mental health conditions, physical abuse, health issues of minors, sexually transmitted disease information, genetic history, and more. They want control to preserve privacy and prevent discriminatory practices that may occur despite legislation forbidding discrimination concerning a variety of health conditions. Clinicians are concerned that vital information may be hidden from them that could adversely affect patient care and increase the risk of medical liability claims. Health insurers are concerned that health conditions could be concealed by applicants that would adversely affect their underwriting process. Finally, some sensitive conditions have a number of associated data elements that could make it difficult to manage privacy directives. An allergy or drug could easily be an indicator for a sensitive diagnosis/condition for example.

The final topic I want to address in this post is the difficulty of acquiring consumer preferences. No standard format is currently utilized. The more discrete the choices offered, the longer it takes to record these choices. How will preferences that conflict be reconciled? Health care organizations have an obligation to educate consumers about their available preferences. This can be a time-consuming process that could tax the health care delivery resources of a practice or organization. Is it fair to place the responsibility for all this education on providers? The Agency for Health Care Research and Quality (AHRQ) has a toolkit to help clinical researchers with these tasks. The site has valuable information for all involved in the area of informed consent. The technology to collect consumer preferences is not mature. Additional standards need to be developed and rigorously tested. How granular should consumer preferences be? How do we apply the opt-in vs. the opt-out approach? We know there is a large disparity between choices made with one approach compared to the other. This is rapidly evolving area in health information technology. There are many vocal, concerned stakeholders. It will be interesting to be involved in future developments in this area.