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
Leveraging Metaphors
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
FAIL
ConstrainThen Innovate
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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
Order
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
User
Formulary Recognition
Allergy Entry
Fitt’s Law
Fields on Demand
Fields on Demand
Design Strategies
• Leverage Metaphors• Constrain Then Innovate• Set Gravity in the Right Direction
Demo
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
Establish Requirements
• Functional Requirements• Usability Requirements– Efficiency– Learnability– Memorability– Safety (error avoidance)– Utility (usefulness)
• User Experience Goals
Establish Requirements
• 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
Order
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
Order
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
SiOrder
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
SiOrder
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
Simvastatin-----------------------------------------------------------SibutramineSildenafilSilodosinSimethiconeSilver SulfadiazineSimvastatin
SimvastatinOrder
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
MedicationStrengthInstructions
Simvastatin20mgqpm with food
QuantityRefills
Indication Hyperlipidemia
Add to Cart
SimvastatinOrder
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
MedicationStrengthInstructions
Simvastatin40mgqpm with food
Quantity #60Refills 2
Indication Hyperlipidemia
Add to Cart
Order
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
Simvastatin 40mg qpm with food #60 2 refills Sign Orders
Order
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
Lisinopril 10mgLisinopril
MedicationStrengthInstructions
Lisinopril10mg1 tab daily
Quantity QS 2 monthsRefills 2
Indication Hypertension
Add to Cart
Simvastatin 40mg qpm with food #60 2 refills Sign Orders
LisinoprilOrder
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
MedicationStrengthInstructions
Lisinopril10mg1 tab daily
Quantity QS 2 monthsRefills 2
Indication Hypertension
Add to Cart
Simvastatin 40mg qpm with food #60 2 refills Sign Orders
CHF
CHF
Order
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
Simvastatin 40mg qpm with food #60 2 refills Sign Orders
Lisinopril 10mg daily QS 2 months 2 refills
TSHOrder
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
Simvastatin 40mg qpm with food #60 2 refills Sign Orders
Lisinopril 10mg daily QS 2 months 2 refills
Thyroid Stimulating Hormone (TSH)
Thyroid Stimulating Hormone (TSH)Order
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
Simvastatin 40mg qpm with food #60 2 refills Sign Orders
Lisinopril 10mg daily QS 2 months 2 refills
Lab NameStart TimeComments
TSHToday
Indication
TSHOrder
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
Simvastatin 40mg qpm with food #60 2 refills Sign Orders
Lisinopril 10mg daily QS 2 months 2 refills
Lab NameStart TimeComments
TSHToday
Indication HyperHyperlipidemiaHypertension--------------------HypercalcemiaHyperesthesiaHyperlipidemiaHyperkalemiaHypernatremia
TSHOrder
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
Simvastatin 40mg qpm with food #60 2 refills Sign Orders
Lisinopril 10mg daily QS 2 months 2 refills
Lab NameStart TimeComments
TSHToday
Indication HyperthyHyperthyroidism
TSHOrder
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
Simvastatin 40mg qpm with food #60 2 refills
Lisinopril 10mg daily QS 2 months 2 refills
Lab NameStart TimeComments
TSHToday
Indication Hyperthyroidism
Add to Cart
Sign Orders
Order
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
Simvastatin 40mg qpm with food #60 2 refills Sign Orders
Lisinopril 10mg daily QS 2 months 2 refills
TSH Draw Today
Order
Simvastatin 40mg qpm with food #60 2 refills
Lisinopril 10mg daily QS 2 months 2 refills
TSH Draw Today
Hyperthyroidism
Password
Logout No
Sign Orders
Order
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
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
Order
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
Batch Renewal v2
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
Order
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
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
Order
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mg
Simvastatin 20mg
Advair 250/50
HCTZ 25mg
Ambien 10mg
Sertraline 100mg
Wellbutrin 150mg
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
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
Order
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
Batch Renewal Keyboard (Ctrl+R)
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
Lisinopril 10mgSimvastatin 20mg
HCTZ 25mg
Sertraline 100mg
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Order
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
Lisinopril 10mg
First Rx: 9/2/95Last Refill: 5/1/10Compliance: Fair
10mg Daily
Lisinopril
Drug Information
NAVIGATION
Order
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
Order
ProblemsHypertensionHyperlipidemiaCOPDCHFInsomniaDepressionAnxiety
MedicationsLisinopril 10mgSimvastatin 20mgAdvair 250/50HCTZ 25mgAmbien 10mgSertraline 100mgWellbutrin 150mg
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 Are We Today?
Where Are We Today?
Where Are We Today?
Where Are We Today?
Where Are We Today?
Where Are We Today?
Where Are We Today?
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?