Designing Usable Healthcare Applications

Designing Usable Healthcare Applications: From Theory to Reality

Jon Duke, MD, MSNovember 21st, 2013

The Need for Innovation in EMR Design

• The required or expected functionality of EMRs is increasing

• Concerns over usability have been longstanding and will be exacerbated as functionality grows more complex

We’ll Get to This Stuff

Functionality Usability

But Let’s Start Here

Strategies for Achieving This Balance

• Leverage Metaphors• Constrain Then Innovate• Set Gravity in the Right Direction

LeverageMetaphors

Leveraging Metaphors

Workflow Wizard

• Goal was to support multiple workflows for each user type based on– Role (e.g., MD, RN, Dietitian)– Training Level (e.g., Attending, Resident, Student)– Specific Permissions

• Creates a Wizard-like guide for each

Workflow Wizards

E-Commerce

Batch Operations

Smart Autocompletion

ConstrainThen Innovate

140 characters

hashtagsretweetsurl shortenersbrevity

InstagramVineYammerWaze

Screen Real Estate

• At outset of development process, set aside an untouchable area of screen real estate

• Area was envisioned for a variety of information needs but was not instantiated for > 1 year

DSS / Stream

ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety

MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg

Concurrent Access

• Our previous system did not allow multiple users performing actions on the chart simultaneously

• Sought to allow this behavior while maintaining patient safety and avoiding database conflicts

Set Gravity in the Right Direction

Right Thing

Wrong Thing

Formulary Recognition

Allergy Entry

Fitt’s Law

Fields on Demand

Design Strategies

• Leverage Metaphors• Constrain Then Innovate• Set Gravity in the Right Direction

Overview

• Overview of Application Design Process• From Theory to Reality: Designing the G3

Physician Order Entry System• Challenges and Lessons Learned• Discussion

Iterative Design Overview

Models &Specifications

Demos & Products

User Requirements

Design, Conceptual & Physical

Prototyping & Construction

Evaluation & Feedback

Establish Requirements

• Functional Requirements• Usability Requirements• User Experience Goals

• Functional Requirements• Usability Requirements– Efficiency– Learnability– Memorability– Safety (error avoidance)– Utility (usefulness)

• User Experience Goals

• Functional Requirements• Usability Requirements• User Experience Goals– Satisfying– Reliable– Trustworthy– Enjoyable– Motivating– Helpful

Requirements Gathering

• Ethnographic Observation• Interviews with Clinicians• Review of Existing Systems• Health IT Domain Experts

Conceptual Design

• Conceptual Model– a description of the proposed system in terms of a

set of integrated ideas and concepts about what it should do, behave, and look like

– Includes artifacts, relationships, workflows– Seek to communicate and match developer’s

mental model to user’s mental model

Conceptualizing the Interface

• Interface Metaphor– Combine familiar concepts and representations,

leverage existing ideas and known solutions• Interface Mode– Instructing– Conversing– Manipulating– Exploring

• Interface Paradigm– Desktop, mobile, wearable, ubiquitous, etc

User Centered Design Methods

• Personas– hypothetical archetypes of real people– derived from field research on users

• Scenarios– fictional story describing a user’s interaction with the

application to achieve one or more goals– Incorporates personas and their environment

• Use Cases– Generic description of action-response functionality of

a system, does not incorporate particulars of a user

Prototyping

• Low Fidelity– Purposely non-realistic, encourages ideas and

rapid iteration• High Fidelity– Increased similarity to final product– Provides better sense of the user experience

Usability Testing

• From prototypes to early stage development• Test early, Test often– 3-5 users sufficient

• Cognitive Walkthrough– Scenarios / Task Analysis– Think-aloud– Interviews

Heuristic Evaluation

• Evaluate system’s adherence to accepted usability principles (‘heuristics’)

• Examples– Recognition over Recall– Forgiveness– Feedback– Consistency– Simplicity

Iterate!

Models &Specifications

Demos & Products

User Requirements

Design, Conceptual & Physical

Prototyping & Construction

Evaluation & Feedback

Theory to Reality

• Regenstrief has maintained a CPOE at Wishard Hospital for >30 years

Updating a Classic

• The Gopher system has been used by thousands of physicians

• Its developers iterated on the system for decades, enhancing its functionality, usability, and speed

• Gopher-based research provided much of the seminal knowledge on CPOE and CDS

• While beloved, DOS-based Gopher is headed for retirement at the end of 2011

Welcome to G3!

G3 UI Design- May 2010

G3 Requirements

• Formal Requirements• Functional, Usability, and User Experience Goa

ls• Workflow

Initial Conceptual Design for Ordering

• Interface Metaphors– e-Commerce / “Order Cart”– Web-style Navigation for workflow– Streams (a la Twitter) for additional information

• Interface Type– Instructing

• Interface Paradigm– Desktop– Do not rule out mobile

Low Fidelity Prototyping

NAVIGATION

DSS / Stream

SiOrder

Simvastatin-----------------------------------------------------------SibutramineSildenafilSilodosinSimethiconeSilver SulfadiazineSimvastatin

SimvastatinOrder

MedicationStrengthInstructions

Simvastatin20mgqpm with food

QuantityRefills

Indication Hyperlipidemia

Add to Cart

SimvastatinOrder

Simvastatin40mgqpm with food

Quantity #60Refills 2

Indication Hyperlipidemia

Add to Cart

Simvastatin 40mg qpm with food #60 2 refills Sign Orders

Lisinopril 10mgLisinopril

Lisinopril10mg1 tab daily

Quantity QS 2 monthsRefills 2

Indication Hypertension

Add to Cart

LisinoprilOrder

Lisinopril10mg1 tab daily

Quantity QS 2 monthsRefills 2

Indication Hypertension

Add to Cart

Lisinopril 10mg daily QS 2 months 2 refills

TSHOrder

Thyroid Stimulating Hormone (TSH)

Thyroid Stimulating Hormone (TSH)Order

Lab NameStart TimeComments

TSHToday

Indication

TSHOrder

TSHToday

Indication HyperHyperlipidemiaHypertension--------------------HypercalcemiaHyperesthesiaHyperlipidemiaHyperkalemiaHypernatremia

TSHOrder

TSHToday

Indication HyperthyHyperthyroidism

TSHOrder

Simvastatin 40mg qpm with food #60 2 refills

TSHToday

Indication Hyperthyroidism

Add to Cart

Sign Orders

TSH Draw Today

Simvastatin 40mg qpm with food #60 2 refills

TSH Draw Today

Hyperthyroidism

Password

Logout No

Sign Orders

Lisinopril 10mgSimvastatin 20mg

HCTZ 25mg

Sertraline 100mg

Lisinopril 10mg daily QS 2 months 2 refillsSimvastatin 50mg daily QS 2 months 2 refillsHCTZ 25mg daily QS 2 months 2 refillsSertraline 10mg daily QS 2 months 2 refills

Batch Renewal v1

Batch Renewal v2

MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mgBatch Renewal v3

MedicationsLisinopril 10mg

Simvastatin 20mg

Advair 250/50

HCTZ 25mg

Ambien 10mg

Sertraline 100mg

Wellbutrin 150mg

MedicationsLisinopril 10mg

Simvastatin 20mg

Advair 250/50

HCTZ 25mg

Ambien 10mg

Sertraline 100mg

Wellbutrin 150mg

Batch Renewal Keyboard (Ctrl+R)

Lisinopril 10mgSimvastatin 20mg

HCTZ 25mg

Sertraline 100mg

1234567

Lisinopril 10mg

First Rx: 9/2/95Last Refill: 5/1/10Compliance: Fair

10mg Daily

Lisinopril

Drug Information

NAVIGATION

Usability Testing

• Cognitive walkthroughs– Physicians in clinic– Residents in hospital– Rotating students

• Heuristic Evaluation– HCI domain experts– Clinical informatics experts

Iterative Development

• Improved core functionality• Removed non-core Functionality• Refined Usability– Speed– Feedback– Status– Language

Where have we gone?

• 2010 Demo

Where Are We Today?

Top Development Challenges

• Time• Complexity / Scope• Prioritization• Core Development vs Responsiveness to User

Needs• Team Management• Multiple Stakeholders

Lessons Learned

• Define requirements clearly up front• Generate detailed specifications• Gives developers ownership of tasks and

sense of impact of project• Respect roles and process• Test with users frequently, iterate based on

evidence, avoid capricious changes

Lessons Learned

• Simple things can be very hard• Brilliant things can be very easy• Don’t lose the forest for the trees• Grow small• Embrace your failures• Innovation matters, whatever they say

What Are Your Projects?

Thanks!

Questions?jonduke@regenstrief.org

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