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PRINCIPLES OF USABILITY
How to Design Efficient and Intuitive
Information Technology for the Health
Care Setting
Katherine E. deS
HIM 501
December 2014

OBJECTIVES
Upon completion of this presentation the learner will be able to:
Define usability
Identify the hallmarks of a usable system
Differentiate usability from user satisfaction
Identify how usability relates to electronic medical record (EMR) design
Identify the principles of usability with examples of each

DEFINING USABILITY
Identifying Components of a Usable System

WHAT IS USABILITY?

Usability is the effectiveness,

efficiency and satisfaction with which
specific users can achieve a specific set of
tasks in a particular environment
(HIMSS, 2009, p. 3)

WHY IS USABILITY IMPORTANT?

Systems that are usable are more easily

adopted by end users
In health care, usable systems increase
patient safety

WHAT ARE THE HALLMARKS OF A USABLE

SYSTEM?

A Usable System:

Is easy to use
Is effective
Is intuitive
Is forgiving of mistakes

Allows users to perform necessary tasks quickly

Allows users to perform tasks with a minimum of mental effort
Completes tasks in the background which helps to:
Improve accuracy
Free up the users cognitive resources for other tasks

(HIMSS, 2009, p. 3)

HOW IS USABILITY DIFFERENT FROM USER

SATISFACTION?
To say that usability is the same as user satisfaction is an
oversimplification (HIMSS, 2009).

Usability involves using evaluation tools that

are objective, repeatable and cost-effective
to measure efficiency and effectiveness

(HIMSS, 2009, p. 1)

HOW IS A SYSTEM DESIGNED FOR USABILITY?

Understand
the Needs of
Users

Use
Established
Methods of
Iterative
Design

Perform
Appropriate
User Testing

EMR USABILITY
Applying Usability Concepts to the Health Care Environment

WHO ARE THE CLINICAL USERS OF EMRs?

Physicians

Nurses

Pharmacists

Physical Therapists

Respiratory Therapists

among others

WHY IS IT DIFFICULT TO DESIGN USABLE EMRs?

There are a wide

range of needs

These needs vary from setting to setting

The needs are different for different

administrative, financial, and

clinician groups

different needs from task to task

Within any identified group, there are

There are over

Nurses, pharmacists, physical therapists, respiratory therapists, medical dieticians

and others all have different software needs

Each discipline may have several

2009, p. 3)

50 physician specialties with different software needs

different task scenarios in a day

(HIMSS,

WHY IS IT DIFFICULT TO DESIGN USABLE EMRs?

Clinicians must focus
on the patient first
They are often mobile and go from
room to room and building to building
They multitask when using software:
talking, thinking or listening at the
same time
Agendas change during a single
patient encounter
Interruptions are common (HIMSS, 2009)
Photo credit: Peter Tyson/ WGBH Educational Foundation

WHY IS IT DIFFICULT TO DESIGN USABLE EMRs?

Administrative and
Financial Concerns
Complicate routine tasks by requiring
billing codes, drug formulary coverage
or prior authorization

Requirements vary with different

Insurers
Emphasis on measuring quality of
care, which is further complicated by
multiple standards (HIMSS, 2009)
Photo credit: Peter Tyson/ WGBH Educational Foundation

WHY IS IT DIFFICULT TO DESIGN USABLE EMRs?

Limited Access to
Clinician Users
Busy Physicians have limited time for
design work
Clinician confidentiality concerns in
encounters
Frequent interruptions in clinician
workflow
Difficult to test in the actual working
environment (HIMSS, 2009)

WHAT IS THE IMPACT OF NEGLECTING USABILITY?

Poor Usability = Compromised Patient Safety

The National Research Council (NRC) has asserted that todays clinical systems provide poor support for the
cognitive tasks and workflow of clinicians (HIMSS, 2009, p. 4)
The Joint Commission reported that approximately 25% of medication errors included in the 2006 Pharmacopeia
MEDMARX involved computer technology as a contributing cause (HIMSS, 2009, p. 4)

How Was a Lack of Usability to Blame?

Alert Fatigue
Screen Fragmentation
Terminology Confusion
Lack of Appropriate Defaults (HIMSS, 2009)

HOW CAN WE DESIGN USABLE EMRs?

Utilize design principles that will create

the most effective user interfaces :
Simplicity
Naturalness
Consistency

Minimizing Cognitive Load

Efficient Interactions
Forgiveness and Feedback
Effective Use of Language
Effective Information Presentation
Preservation of Context (HIMSS, 2009)

USABILITY PRINCIPLES
Designing for Effective Use

Principle: SIMPLICITY

Less is More
Remove visual clutter
Only include what is needed to accomplish a task
Use easy to read displays
Make important information stand out
Clean screen design

Move some complexity under the hood (HIMSS, 2009)

Principle: SIMPLICITY

Less is More

So
how
would
this
Only include what is needed to accomplish a task
look if we
Use presentation
easy to read displays
Make important information stand out
ignored
the
principle
of
Clean screen design
Move some complexity
under the hood ?
simplicity

Remove visual clutter

(HIMSS, 2009)

Defining and Testing EMR Usability Principle #1:

SIMPLICITY
A Less is More philosophy is appropriate, with emphasis being
given to information needed for decision making (HIMSS, 2009, p. 5).

You would want to make sure that you remove visual clutter, since having too much on
one screen distracts the user and contributes to visual fatigue

You want to make sure that you only include what is needed to accomplish a task and
dont add a bunch of extra stuff that doesnt need to be there just because one person
thinks that that thing is important there.

You want to make sure that you use easy to read displays because easy to read displays
are better for the learner and will contribute to patient safety.

Make important information stand out

Use a clean screen design that doesnt have too much stuff on it and that has colors that
go nicely together

Move some complexity under the hood (HIMSS, 2009)

Principle: SIMPLICITY

See the Difference?

Principle: NATURALNESS

How automatically familiar the

application feels
Terminology used is familiar
Interface flows as the user would expect
Works naturally with users workflow

Principle: NATURALNESS
Children can often pick up and start using
Apples iPads almost immediately

Why?
The naturalness in gesture-control
devices enables children to reflect real
world situations into the interaction (Muhammad,
Nazlena & Masnizah, 2013)

Gaglias, P. (2014, October 14). Ipad [photograph]. Retrieved from Flickr.com

The performance of the

device feels natural and
requires little, if any, training

Principle: CONSISTENCY

An application needs both

internal and external
consistency

Principle: CONSISTENCY

An application needs both internal and external

consistency
Internal Consistency: The concept, behavior, appearance and layout are
consistent throughout
Example: You are able to navigate new online learning courses every
semester. Why? Because the formatting of the online learning program
is similar from course to course.
External Consistency: The application behaves similar to other software
applications the user has experienced before
Example: You are able to get in a new car and start driving it almost seamlessly.
Why? Because the car behaves similar to cars you have driven before.

Principle: MINIMIZING COGNITIVE LOAD

What Contributes to
Cognitive Overload?

Time pressure

Multiple demands for attention

Staggering information load

(HIMSS, 2009)

Cognitive Overload Negatively

Affects Patient Safety!

Principle: MINIMIZING COGNITIVE LOAD

What Increases Cognitive Load?
A design that isnt simple, natural and consistent
A design that makes the user rely on memory rather than visual
recognition
When information needs to be remembered from one screen to
the next
When the user needs to remember tricks to make the
application run properly (HIMSS, 2009)

Principle: MINIMIZING COGNITIVE LOAD

How Can a Usable EMR Reduce Cognitive Overload?
Present all the information needed for the task
Example: When a patients lipid results are reviewed, the previous
results, medication list, and allergy list are in the same visual field)

Organize information by meaningful relationships

Strive for transparency. The user should not have to think
about using the application.

Principle: EFFICIENT INTERACTIONS

For users to accept a clinical

application, they need to spend as
little time as possible entering data
into it

Principle: EFFICIENT INTERACTIONS

How Do You Make Interactions More Efficient?

Minimize the number of steps it takes to complete tasks

Provide shortcuts for experienced users

Auto-tabbing

Good default values

Limit scrolling

Limit keyboard/mouse switching

Limit cursor travel distance

Limit visual scanning

Example: One step quick order entry for commonly used admission orders

Principle: FORGIVENESS AND FEEDBACK

Forgiveness: The user can discover through
exploration without fear of disastrous results
Accelerates learning
Built-in protections against unintended
consequences

Feedback: Informs the user about the effects of

the action he is about to take
Reassures users that actions will have desired
effect

Principle: FORGIVENESS AND FEEDBACK

Examples:
Forgiveness: A Physician using a new EMR systems wants to modify a
template for patient encounters. She knows that, if she accidentally
makes an error on the new template, the original will still be available for
her to use.
Feedback: A nurse on the maternity unit is about to link the charts for a
mother and her newborn. The computer notes that the newborn and
mother have different last names, and prompts the nurse to see if she
wants to proceed with the link.

Principle: EFFECTIVE USE OF LANGUAGE

All language in an EMR should be

concise, unambiguous, and
meaningful to the end user

Principle: EFFECTIVE USE OF LANGUAGE

All language in an EMR should be

concise, unambiguous, and
meaningful to the end user

How do we do this?

Principle: EFFECTIVE USE OF LANGUAGE

Avoid computer technology terms in the interface
Never display text in all upper case
Avoid abbreviations and acronyms, except when searching
Capture structured clinical terms from provider
documentation (HIMSS, 2009)
Example: BMP is spelled out as Basic Metabolic Panel in
the order entry, but a search for BMP will bring up the
order

Principle: EFFECTIVE INFORMATION PRESENTATION

For the presentation to be effective,

pay close attention to the displays
density, color, and readability
(HIMSS, 2009)

Principle: EFFECTIVE INFORMATION PRESENTATION

Density

Limit visual density

Limit screen changes

Color

Readability

Use to convey
meaning
Limit aesthetic use
Use simplicity and
consistency
Use san serif fonts
Watch font size
High contrast
between text and
background

Principle: EFFECTIVE INFORMATION PRESENTATION

Limit visual density

Density
Limit screen
changes
Avoid the temptation to pack
as much
as possible onto the
screen
Search times and user errors increase in proportion to density
Use to convey
Consider character count, resolution,
font, font size and
meaning
grouping techniques
Limit aesthetic use
Color
Also consider screen
elements
such as lines, buttons, controls,
Use simplicity and
scroll bars and icons
consistency
Use 40% density or less for character based displays, less for
graphical interfaces
Use san serif fonts
When drilling down use 80/20
80% of the time summary
Watchrule:
font size
informationReadability
is enough, 20%
of the
time the user may seek
High
contrast
text and
more information (HIMSS, 2009, p. between
8)
background

Principle: EFFECTIVE INFORMATION PRESENTATION

Avoid the temptation to pack as much as possible onto the
screen
Search times and user errors increase in proportion to density
Consider character count, resolution, font, font size and
grouping techniques
Color
Also consider screen
elements such as lines, buttons, controls,
scroll bars and icons
Use 40% density or less for character based displays, less for
graphical interfaces
When drilling down use 80/20 rule: 80% of the time summary
information is enough, 20% of the time the user may seek
more information (HIMSS, 2009, p. 8)

Principle: EFFECTIVE INFORMATION PRESENTATION

Poorly utilized in current system designs
Should be used to convey meaning to the user
Should be consistent throughout the program
Example: If red signals a critical lab value, then it
should only signal a critical lab value
Should account for users with colorblindness by using
Color
redundant encoding
Adheres to cultural conventions

RED: Danger or Warning

YELLOW: Caution, Requires Attention
GREEN: Safe, Normal
BLUE: Advisory

Principle: EFFECTIVE INFORMATION PRESENTATION

Poorly utilized in current system designs
Should be used to convey meaning to the user
Should be consistent throughout the program
Example: If red signals a critical lab value, then it
should only signal a critical lab value
Should account for users with colorblindness by using
redundant encoding
Adheres to cultural conventions

RED: Danger or Warning

YELLOW: Caution, Requires Attention
GREEN: Safe, Normal
Readability
BLUE: Advisory

Principle: EFFECTIVE INFORMATION PRESENTATION

Decisions will sometimes be based upon a quick screen review

Allow users to modify text sizes
Utilize san serif fonts because they are more easily read on
screen
Use high contrast between text and background

Readability

Principle: PRESERVATION OF CONTEXT

Keep screen changes and visual

interruptions to a minimum during
completion of a particular task

(HIMSS, 2009, p. 10)

Major Culprit Dialogue Box!!

Principle: PRESERVATION OF CONTEXT

How Do You Preserve Context?
Minimize dialogue boxes! They should be near the control that
triggered them
Directness dont have separate entry vs viewing modes

Questions?

REFERENCES

Gaglias, P. (2014, October 14). Ipad [photograph]. Retrieved from Flickr.com

Healthcare Information and Management Systems Society [HIMSS] (2009, June). Defining
and testing EMR usability: Principles and proposed methods of EMR usability evaluation
and rating. HIMSS EHR Usability Task Force. Retrieved from
http://www.himss.org/files/HIMSSorg/content/files/HIMSS_DefiningandTestingEMRUsabilit
y.pdf

Muhammad, S.A., Nazlena, M.A., and Masnizah, M. (2013). A Study on the naturalness of
gesture-based interaction for children. Lecture Notes in Computer Science, 8237, 718728. doi: 10.1007/978-3-319-02958-0_65

Tyson, P. (2001). Multitasking doctor in the ER [photograph]. Retrieved from

http://www.pbs.org/wgbh/nova/body/one-night-emergency-room.html