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.