How do you design usable systems for nurses?

The Tiger Initiative has been working on the usability of clinical applications for some time now. They just published a report with recommendations. I know a few of the people involved. It's worth a look. Link

Since 2007, hundreds of volunteers have joined the TIGER Initiative to continue the action steps defined at the Summit. The TIGER Initiative is focused on using informatics tools, principles, theories and practices to enable nurses to make healthcare safer, more effective, efficient, patient-centered, timely and equitable. This goal can only be achieved if such technologies are integrated transparently into nursing practice and education. In order to meet the demands of an increasingly electronic and rapidly changing healthcare environment, it is essential to address the educational needs of the nursing workforce.

STAR Moments

I'm in a nice local coffee shop, trying to build a presentation about EMR Usability. Christmas music is playing in the background, some of it actually unique.

I think of myself as an evangelist for EMR usability.

How can I deliver a S.T.A.R. Moment for the audience? What is a S.T.A.R. Moment? It stands for "Something They'll Always Remember".

A couple of examples from Nancy Duarte's blog.

What I want for Christmas is an inspiration.

Maybe it will be some dramatic illustration of how often doctors get interrupted, or how much time it takes to do some paltry task, or how long it takes to tell a story in a progress note. Or bringing along an old Underwood typewriter. Or a tableful of clocks or timers.

What's the message?
Usability matters. Here's what it looks like. Give me some.

A Beautiful EMR Note!

I don't get to say this often, but this is a beautiful progress note produced by a commercial EMR. Most progress notes from EMRs look like the company fired all the people who had an eye for page layout and design.

click image below to see enlarged view


Here's what I like about this note:

  • It's visually inviting, with a very clean look.
  • Effective use of font choice, bold headers, left-alignment, rules of proximity and spacing (see prior post on C.R.A.P. design principles).
  • The left hand column gets the less critical Past History details (yellow highlight added) off to the side. This allows me to know they are out of the way as I scroll, but remain available at a glance. This should be standard in all EMRs, in my opinion.
  • I can skip directly to the sections of interest (pink highlighted added) to answer the questions: "why was this patient seen, what did the consultant think, and what is the plan?"

What could be improved?

  • Move the Assessment and Plan to the top of the note. That's what almost every reader is looking for. Why not put it first? I have a few consultants who do that routinely in their dictations, and it's always a hit.
  • Enhance the Vital Signs so they are easier to read. Add bold to labels, add more space between items.
Temp 97.0, BP 154/106, HR 77, Wt 235.4 lbs
  • Lose the underlining. It would look better this way (bold, and a step bigger)


Your thoughts, readers?

Making Lists of Diagnoses to Pick From


If I can't get a list with predictive search (where the search field starts guessing what I want from the few characters I've typed so far), then at least give me a heads-up list on one page. Make the list short and comprehensive enough.

I want to find about 80% of my commonly used diagnoses on one page, then multi-select all the diagnoses that I need, and then click "OK". If I can do that, I will be very happy. I've seen it done in at least one EMR.

See, I'm not hard to please.

How would you build the list?

  1. Make a fairly comprehensive list first, sorted by how often I (or family physicians in general) select that diagnosis.
  2. Then create the list on a page or two.
  3. Then add columns (to allow more items) and shrink the font until it is still readable. Test readability with a few 50-60 year old users wearing bifocals.
  4. Trim the list to one (or two, A-L and M-Z) pages.

What are the user-centered-design principles?

  1. Get it on a single visual plane in plain sight. (expand to a second page, if needed, or if users wanted it).
  2. List alphabetically. Avoid organ system grouping, which takes more cognitive effort and more visual scanning time.
  3. Use simple, frequently-used-by-clinician word choice (e.g. “headache” instead of “cephalgia”).
  4. Put most relevant words first (e.g. “diabetes mellitus, type 2”, not “type 2 diabetes”)
  5. Make font big enough to read.
  6. Eliminate words that don’t add benefit for user (e.g. for “250.41 Diabetes 1 w/ renal changes”, do include “w/ renal changes”. For “250.00 Diabetes 2 uncomplicated”, I’d argue that the “uncomplicated” is optional, and takes up space).

The single page has some advantages over the predictive search, which can only do one diagnosis at a time.

  • I don't have to use the keyboard.
  • I can select 6 diagnoses with only 6 clicks.
  • I press OK once, and not 6 times.
  • I can go a lot faster.
  • I'll develop muscle memory finding the commonly picked items on the page (could pick them blindfolded!).

Go ahead. Make my day.

Testing & Rating EMR Usability

I just finished writing a white paper for HIMSS titled "Defining and Testing EMR Usability: Principles and Proposed Methods of EMR Usability Evaluation and Rating". It's publicly available at this link.

It has been a great team to work with. Many thanks to my Human-Computer Interaction co-authors, Rebecca Grayson and Janey Barnes. They brought experience with clinical systems and their body of user-centered design knowledge to the task. Thanks also to the team leaders Penn White MD and Tiana Thomas for harnessing the power of a cadre of volunteer contributors to the effort.

Briefly, this paper describes how poor EMR usability has hindered user adoption among physicians and hospitals. We describe a number of usability principles that apply to EMRs in particular, and then offer evaluation and testing methods for finished EMR products, and suggest ways to rate the EMRs.

Our hope is that certifying and rating organizations such as Certification Commission for Healthcare Information Technology (CCHIT) or the American Academy of Family Physicians (AAFP) will be able to use this work in developing their own rating methods that can help EMR purchasers.

Don't Make Me Think

I love this line.

It's the title of one of my favorite books on software usability, written by Steve Krug.

The human-computer interaction pros refer to this principle as "reducing cognitive load." Don't waste precious brain resources on stuff the application should be able to do quickly, accurately, and invisibly.

Here's a prime example.

In displaying lab results, why not do the math for the clinician user? Don't make me calculate how long ago the last lab result was obtained. Tell me it was about 2 weeks ago. The precision can get more relaxed the longer ago the result was obtained.


The same principle applies to displaying the patient's age. Don't just show me the date of birth. Do the math for me.

I have plenty of more important things to think about.

EHR's should help clinician users manage the whirlwind of Childhood Immunizations


As a family physician for about 30 years now, and former “Immunization Czar” in my private practice, I lament the current state of Childhood Immunizations.


I lament the simple olden days, when a few immunizations existed, and new ones came along rarely.

I could memorize the list, and provide advice and prevention efficiently.

For simplicity, I will only refer to childhood immunizations here. Adult immunizations have some unique features.

Progress brought complexity.

New vaccines came along every year. The guidelines changed every year, in stages (ACIP recommended; then later all the authorities approved; then insurance payors reimbursed; and finally states mandated). I had new memorization to learn every year. Sometimes, I had blowback: a vaccine was not yet covered by insurance, or it was in short supply, or it required a new refrigerator for which we had neither space nor funding.

Now, it’s even more complex:

  1. We have rolling shortages, which might be national or local.
  2. We have combination vaccines, in overlapping, but not identical patterns.
  3. A particular single component vaccine might be available from two different manufacturers, but have different admin schedules (3 doses for one, but 4 doses for the other).
  4. Government-sponsored programs might require special ordering and tracking. The government choice of vaccines might differ from my organizations prior choices.
  5. Consumers are demanding customizations (break up my MMR into the 3 separate components) that fragment and complicate matters even further. This item alone could have me ranting for pages. I won’t rant, for now.
  6. The CDC schedule is offered as a range of choices, adding complexity at most well child visits. I order as individual vaccine components (MMR, or Tdap, or HiB/HepB). The nurse draws up the vaccine from a bottle marked with a brand name. He or she might have to adjust for temporary shortages, using Pediarix one week, and something else next week, depending on local supplies.

How can a human brain handle all this?
Not very well.

How can this be safe?
I think it is not.

How can this be made more efficient?
Our software could do this, but the design requirements are challenging.

Ideally, the decision support would be embedded in our EHRs.

The vaccine requirement/availability database that is used by our EHR would be maintained nationally, by the CDC, or by another entity along the lines of Multum (which maintains prescription drug databases).

The availability database could be modified locally, to reflect institutional formulary choices, or pharmacy shortages.

The decision support would examine a patient’s age, previous immunizations, and recommend a preferred dose for today (and acceptable alternatives).

The EHR database would communicate with regional or national immunization registries. That way, patients who move, or who must change providers, or who use multiple providers (the ED, the primary care physician, the developmental pediatrician, the pulmonologist) would have their immunization progress schedule available to all the providers.

Dear reader, do you know of an application or institution doing it well?

Jeff Belden MD