View source for Using qualitative studies to improve the usability of an EMR

This is a review for Alan F. Rose, Jeffrey L. Schnipper, Elyse R. Park, Eric G. Poon, Qi Li, and Blackford Middleton application of qualitative guidelines in the assessment and improvement of EMR usability. <ref name="Rose 2005">. Creating Using qualitative studies to improve the usability of an EMR. J Biomed Inform. 2005 February ; 38(1): 51-60. http://dx.doi.org/10.1016/j.jbi.2004.11.006</ref>

== Research question ==

Are studies based on qualitative data efficacious in helping improve the [[usability]] of [[EMR|electronic health records (EMR)]] and if so what design solutions can be recommended?  

== Methods ==

=== Environment ===

Two separate qualitative studies that attempted to identify user task flows with an existing EMR, to better understand the environment in which these tasks are performed, and to determine how overall usability can be improved.

=== Design ===

Each of the qualitative studies focused on users of the Longitudinal Medical Record (LMR), a web-based application that facilitates the management of patient information, provides clinical messaging, and standardizes methods of data entry and retrieval.  Then the following three forms of evaluation were applied:

* '''Task Analysis''': Task analysis clarifies the objectives of each task, which tasks are most important to users, and which tasks depend on other tasks

* '''Focus Groups''': Focus groups are an informal and relatively unstructured exercise that can help assess user needs and feelings both before and after system design

* '''Collaboration''': Task analysis and focus group studies were conducted independently of each other with an agreement between their respective administrators to collaborate and identify common themes during the data analysis phase. This resulted in a joint effort to systematically compare the results of our inspection and propose solutions for enhancing LMR’s usability

=== Measurements ===

Each of the qualitative studies focused on users of the Longitudinal Medical Record, a web-based application that facilitates the management of patient information, provides clinical messaging, and standardizes methods of data entry and retrieval. 

== Results ==

Findings from both studies raised issues with the amount and organization of information in the display, interference with workflow patterns of primary care physicians, and the availability of visual cues and feedback. These findings were then used to recommend user interface design changes.

=== Main results ===

The two qualitative studies showed that there were a lot of consistencies in issues with usability of LMR.  Deficiencies were identified specifically with regard to the following aspects:

'''Navigation'''

Both studies qualified the navigation aspect as "awkward" and subjectively used too many clicks to get data entered or retrieved.   Too many popup menus were offered which crowded the screen.  Physicians created workarounds by opening up multiple browsers which was not ideal as it was time-consuming and consumed the system's resources, slowing down the computer.  

* '''Information Design''' The presentation of the screens created issues.  The Results Manager’s usage of color and low contrast with data objects that are in their “selected” state made it difficult to read or identify the information quickly.  In addition, there was a poor balance of displaying what the provider needed with what was available in "one click away" from the current screen.
* '''Customization''' Comments regarding customization were targeted primarily toward the letter-writing feature in Results Manager. Many physicians often used their own letters and found the pre-defined letter templates of Results Manager to be inadequate for all their workflow needs. 
* '''Workflow''' The participants came from a variety of workflow backgrounds.  Some blocked off time at the end of the day to enter notes, while others entered at the end of each patient visit.  The biggest complaint from workflow again came from navigational issues--specifically the popup menus which slowed productivity.

== Conclusion ==

Through a thorough examination of two studies, it can be shown that qualitative research can help focus attention on user tasks and goals and identify patterns of care.  Findings from both studies found consistency with regards to issues with the organization of information in the display, interference with workflow patterns of primary care physicians, and the availability of visual cues.  

== Commentary ==

Usability engineering can play a valuable role in assisting product design teams, unfortunately it has not been a routine part of designing clinical computing systems.  Upon interviewing many of the test subjects who evaluated the EMR system, some identified system speed to be the primary determinant of user satisfaction, but most felt that usability principles and not speed or technology alone was necessary for the success of the EMR.  Although usability is a broad term, it can be narrowed to two groups via various theories of human cognition and visual sensory perception.

First, it relates to navigation and system content.  This is where efficiency of the EMR comes into play in defining usability.  When efficiency slows down, the physician blames system speed, however technology is not the issue, rather often its the myriad of details and popup menus which create an overload in visual sensation.  The fact that often the users created workarounds by opening multiple browsers reinforced this conclusion.  Navigation and system content needs to be designed around user workflow--not a one size fits all.  Different practice styles from various specialties and personalities come into play.re is

Second, information design is an important aspect of usability.  Cognitive load theory defines the amount of "mental energy" needed to process the information or task in front of the user.  There is a direct relationship between cognitive load and the amount of information present.  Visualization also affects cognitive load as when too many screen elements come close together, the processing of information becomes slowed.  Resolution can decrease efficiency if contrast or colors are not ideal and can mask the visual hierarchy.  

== Related papers ==

* Another one of B. Middleton's papers: [[Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA]]


== References ==
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[[Category:Reviews]]
[[Category:Usability]]
[[Category:qualitative analysis]]
[[Category:Interface, Usability and Accessibility]]