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Usability of Electronic Medical Records

John B. Smelcer, Hal Miller-Jacobs, and Lyle Kantrovich

Journal of Usability Studies, Volume 4, Issue 2, February 2009, pp. 70-84

Article Contents


Directions for Future Medical Systems

Based upon our discussions and observations with the various medical personnel, we are proposing several design directions that future medical systems should consider. These design directions are not necessarily specific to medical systems but are crucial to the success of future systems.

Flexible Navigation Scheme

As we noticed, the road to effective patient care can take many paths, not only by the variety of medical personnel but also within the physician category. It is therefore important to create a flexible navigation scheme that can be tailored to a particular medical environment and even customized by individual physicians. The navigation schemes must reflect the mental model of the medical professional and not those of the designer or even the medical administration.

Figure 5. Possible navigation model with multiple levels

Figure 5. Possible navigation model with multiple levels

One scheme (Figure 5) employs a top level patient tab, a left navigation categorization, a set of relevant sub tabs, and even a further breakdown in the active content area. This model provides rapid access to many patient areas with a minimum number of clicks. The listed items can be tailored to a particular medical system or practice, or even customized to a specific physician. It must reflect the users mental model and in particular their terminology.

Accommodate Specialists

Physicians with different specialties need different functionality and different information. Physicians typically have different specializations: internal medicine, ophthalmology, ENT, radiology, surgery, etc. They need different summary information for each patient and different functionality. An ophthalmologist would see summary information about each patient's visual system and be able to sketch a patient's retina, while an obstetrician would see summary information on the developing fetus and be able to record information on it. Even with a customized user interface, there are individual differences within a specialty. This implies that they need an interface customized for their specialty. However, many individuals will want to personalize that interface for their individual needs to better match their individual task flows and data entry preferences.

Use of Defaults

The pace of work varies greatly across physicians and clinics, from one patient per hour to six or more patients per hour. In the latter situation, typically where acute illnesses like flu and colds are being treated, there is no extra time to thoroughly document each patient visit. However, there are also a small set of problems seen in such clinics. As a result, the interface can dramatically simplify handling common problems, e.g., sore throat. Rather than separately entering the chief complaint, ordering labs, prescribing meds, and typing notes, the interface can record defaults for labs, meds, and notes once the physician selects sore throat as the chief complaint. Obviously, these defaults can be changed if the patient's situation demands it.

There is of course a potential problem with the extensive use of defaults. If the default entry is not verified by a physician, incorrect data may be entered in the patient's record simply because it was included in the default package. This can be problematic, for example, where medications are involved. A thorough analysis must be performed to determine the appropriateness of defaults. It must however be remembered that repetitious entry becomes automatic, even annoying, and essentially serves as a de facto default.

Accessing Multiple Patients

The pace of work also varies in the number of patients being treated at any one time. Physicians who treat multiple patients at any one time by using several exam rooms are often penalized by EMR systems that require them to log out when leaving one room and log in when entering another. The user interface should also support rapidly switching between patients, because physicians are often interrupted during an exam by a high priority call about another patient. The first level of tabs in Figure 5 shows a possible multi-patient navigation scheme. In addition, a usable EMR should allow the physician to inherit the login used by the nurse who took the vitals and recorded the patient's chief complaint to reduce the initial login time. Finally, implementation teams should consider portable tablet PCs so that the physician is always connected and never has to log out or back in.

Appropriate Delegation of Responsibilities

Physicians vary in how they delegate responsibilities to nurses or assistants. In the same way that the physician can inherit the login used by the nurse, the nurse should be able to complete the administrative aspects of the visit, e.g., administer and record inoculations. Parallel work on one patient by both the physician and the nurse requires that the EMR allow simultaneous access to the same patient record, even though many database systems limit simultaneous access. Also, results from the labs ordered by the nurse should go to the physician, not necessarily the nurse. The UI needs to support this redirection quickly and easily, with clear and appropriate redirection status displayed on relevant screens.

Data Entry Variations

Different physicians prefer different methods for entering their notes, primarily because of productivity issues. Those with strong typing skills will prefer to type when entering notes from patient visits. Those comfortable with dictation will prefer to dictate their notes. Others will want to write their notes onto a tablet interface. As well, a tablet interface will also be important for sketching pictures of eyes, hands, and other anatomic characteristics.

However, the method employed for entry affects successful searches for relevant patient information. If physicians enter data as free-form text, then subsequent physicians will struggle to search it for specific information, e.g., "When was this patient's last mammogram?" The answer may be buried in one of dozens of separate notes. There are no easy answers to mitigate this complexity.

Figure 6. Example structured editor for note entry

Figure 6. Example structured editor for note entry

One approach would be to encourage physicians to use structured text (Figure 6). While this approach sounds promising, the usability of the templates must be thoroughly user-tested to ensure that it meets the needs of both data entry and retrieval. As more and more physicians become computer savvy, this problem may diminish.

Data Visualization

Finally, physicians are very intelligent, highly trained individuals solving problems with a very complex system—the human physiology. The interrelations and dependencies with the human body are immense. As EMRs enable physicians to access ever greater amounts of information, they will need to see that information displayed in formats that can be integrated and manipulated. This may involve the use of multiple monitors and sophisticated software. Hospitals and clinics promise to be a fertile ground for data visualization software and for the manufacturers of display hardware.

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