Usability Expert Jakob Nielsen Would Like EMRs / EHRs with Big Targets, Less Functionality and Better Workflow Management

Short link:

In previous posts I’ve argued that most traditional EMRs EHRs with desktop interfaces (monitor, keyboard, and mouse) are wrongheaded and misguided. Instead of mimicking Microsoft’s explicit and implicit user guidelines, resulting in EMRs EHRs that resemble Microsoft Office, they should copy smartphones and tablets.

I’ve written that EMRs EHRs need to

and to do this EMRs EHRs need to become more context-ware/process-aware.

In short,

Neilsen does not appear to have publicly weighed in on EMR EHR lack of usability. But he has commented about smartphone usability experience. His comments are right on, and just as relevant to EMR and EHR usability.

Neilsen says:

“What are the biggest mistakes companies make when building their sites and apps?

  1. Making it difficult to touch and manipulate. As Nielsen explains, your eyes are more agile than your fingers. You see that link among but your fingers can’t select it, so Nielsen recommends using larger touch targets.
  2. Trying to do too much. Those responsible for the mobile UE must be ruthless when fighting internal political battles. Every department wants their content front and center, but when everything is prominent, nothing is prominent, so eliminate the nice-to-have.

Nielsen argues for fewer commands and a few basics on first screen. Use progressive disclosure to build the experience, rather than try to put every option up front. More screens are better if each is simple and focused….

Without context, Nielsen reports, comprehension is degraded. While our brains are great for long-term storage, they fail in the short term. For this reason, people will not use mobile for research or comparing large amounts of information. Don’t require a user to remember things from screen to screen.”

So, consistent or inconsistent with what I’ve been posting?

I say: Consistent!

Jacob Neilsen on Mobile Usability Implications for EMR EHR Usability
“Nielsen recommends using larger touch targets” EMRs EHRs need larger buttons/targets, therefore fewer per screen, therefore fewer total or spread across more screens
“Every department wants their content front and center, but when everything is prominent, nothing is prominent, so eliminate the nice-to-have” Nielsen blames adding everything, including the kitchen sink, to an app on “Politics” — I wonder what he’d think about Meaningful Use?
“Don’t require a user to remember things from screen to screen” That’s part of what EMR EHR workflow management does: a workflow engine executing process definitions does and remembers things for the user (even what screens comes next) reducing EMR EHR user cognitive load

Case closed! Neilsen would agree with me. (I’m so smart!)

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  1. Posted November 11, 2011 at 11:00 am | Permalink

    I’ve been meaning to comment on your article since I first saw it in August. I really like your assessment!

    Obviously the industry is taking note of usability in EHR systems as NIST has just recently put forward their usability evaluation guide (which I understand may be the basis for upcoming meaningful use stage 2 criteria)

    For further reading on EHR usability and the root causes at this time, I invite you to check out my paper 9 Usability Mistakes Your EHR Team is Probably Making (And How To Fix Them)

  2. chuckwebster
    Posted November 15, 2011 at 2:30 pm | Permalink

    What a great white paper!

    All nine actionable insights in Nine Usability Mistakes Your Team is Probably Making (And How to Fix Them) will improve current EMRs and EHRs usability.

    I do have one caveat.

    Your EHR usability insights deserve a more instrumented and malleable EHR substrate than current EHRs typically provide.

    Application of your usability insights to the current generation of structured-document-based EMRs and EHRs will only incrementally improve usability. However, their application to emerging structured-workflow-based EMRs and EHRs could quickly and inexpensively result in dramatic usability improvements.

    Most current EMRs rely on structured-documents, but not structured processes. These EMRs have relatively frozen workflows. To compensate designers crowd too much information and data/order entry options per screen and force users to perform extra work navigating from screen to screen.

    EMRs and EHRs with executable process models (AKA EMR workflow systems, EHR business process management systems, process-aware health information systems) are less work to use by their users. They reduce the physical activity (clicks) and the cognitive work (scanning and interpreting screens, deciding which screen to proceed to next) through execution of a user-editable process model by a workflow engine.

    A process model provides constraining context so all and only relevant information and data/order entry options appear on each screen. The process model also reduces the navigational search space confronting the user.

    Off the top of my head, here’s an outline applying your nine usability insights to process-aware EMRs and EHRs.

    Nine EHR Usability Problems and How to Fix Them with Workflow Technology

    1. 1. Displaying too much information and too many data and order entry options per screen
      • Use process definitions to choose screens
      • Use process definitions to choose what to display
      • Use process definitions to choose how to display
      • Allow user to directly (via software editor) or indirectly (via human scribe) edit process definitions
    2. 2. Focusing on features and functions instead of workflows and processes (so-called EHR “Featuritis”)
      • The whole (workflow/process) really is more than the sum of the parts (features/functions)
      • Follow the 20/80 rule: (the most important) 20% of features in usable form is better than (the most important) 80% of the features in unusable form
    3. 3. Mimicking paper forms instead of replacing them with a “glass cockpit”
      • Earlier aviation cockpit displays simulated physical gauges and switches
      • Current aviation cockpit displays do not
      • Current EMRs and EHRs are still in the “early” phase when they simulate paper forms
    4. 4. Tweaking hunt-and-peck screens instead of facilitating user-redesigned workflow
    5. 5. Not gathering and understanding real-world usability event data
    6. 6. Not respecting Fitts’s and Hicks Laws dictating bigger and fewer targets per EHR screen. (smartphones and tablets currently do this better than most desktop EMRs and EHRs)
      • Fitts’s Law: Larger, closer targets (buttons, hotspots, etc.) are easier to hit quickly and accurately
      • Hicks Law: Users more quickly and accurately choose from among fewer competing alternatives than more numerous competing alternatives
      • Therefore display fewer larger targets per screen (again, made possible through context constraints supplied by during workflow enactment by executable/executing process model)
    7. 7. Not leveraging user-editable process definitions editors to improve screen sequence
      • User testing is all well and good
      • But use it in conjunction with user-editable screens and screen flows
      • The result will be a tighter, more productive edit/execute EMR user interface and user experience improvement loop
    8. 8. Assuming usability ratings equal overall usefulness
      • Just because you can do something
      • Doesn’t mean you want to do something
      • Doesn’t mean you should do something
      • Use who-what-why-when-where-how context to make what you want to do and should do easy to do
    9. 9. Waiting for meaningful use dust to settle before tackling:
      • EMR and EHR workflow with workflow engines (this whole blog)
      • EMR and EHR Usability with user event data (see above)
      • EMR and EHR Safety with process model checking (not discussed above, but see 1, 2, and 3)
      • EHR and EMR Productivity with BPM (business process management)

    Your nine EHR usability mistakes potentially apply to both structured-document-based and structured-process-based EHRs, however their effects are different. Structured-document-based EHRs and EMRs have relatively frozen workflows. They have no means to use workflow execution context (”enactment” in BPM parlance) to intelligently decide at run-time what and how to paint content on each screen and which screens to present in which order based on user who-what-why-when-where-how context. Structured-workflow-based EMRs and EHRs have exactly this means. Combining this means with traditional usability engineering methods promises more systematically improvable EMR and EHR workflow and therefore EMR and EHR usability.

    All in all, your Nine Usability Mistakes Your Team is Probably Making (And How to Fix Them) is a great bundle of insights that will incrementally improve existing EHRs.

    Incremental improvement of EMR and EHR usability is better than nothing in the short run. It won’t be enough in the long run.

    EMRs and EHRs will need to be more “intuitive” (in the correct sense of the word) than will be possible without process models to usefully push screens to user like a good OR nurse hands instruments to a surgeon.

    Thank you for your kind comment and an opportunity to read your white paper.



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