Can't you just include a picture of my pill?

I've been involved in numerous conversations about medication lists that our healthcare organizations give to patients, and meaningful use rules require the lists. I used to think it was a hopeless cause to get the picture of the pill your pharmacist gave you at your last refill into your personal medication list.

I am not so hopeless, but I remain sanguine. The incentives aren't aligned yet among all the stakeholders. The data doesn't flow freely. It's a rare patient that would use their smartphone to photograph their pills (good lighting and backgrounds are hard!) to include them in their Personal Health Record (PHR), if they are one of the rare people who maintain a PHR.

So, to give you a taste of the challenges, here is a short video showing the different colors and shapes of one single generically available pill: lisinopril. I captured it from ePocrates, which is a wonderful tool for providers.



If it's a brand name drug (for example, Crestor), getting a picture is far easier.



There is a code called the NDC code that tells the pharmacist which exact generic version of your lisinopril you are taking, but your doctor doesn't know (or care, generally) which NDC code is your particular lisinopril. But as we (patients, nurses, doctors, and pharmacists) start coming to expect the pill pictures as part of our conversations, then the NDC code sharing will become more important.

It's in our future, but not our present.

Information Chaos

Researchers at the University of Wisconsin recently published a conceptual article on Information Chaos titled "Information Chaos in Primary Care: Implications for Physician Performance and Patient Safety" (J Am Board Fam Med, Nov-Dec 2011, 24:6, 745-751).

Figure from the article at bit.ly/InfoChaos

I had never heard the concept of "Information Scatter" articulated before, but it resonated strongly with my experience as a family physician using a variety of EMRs over the past decade.

I recently did a post on using Information Dashboards. Think of a dashboard serving the same purpose as the dashboard in your car. It gives you the critical information you need for the task at hand.

• When you start the car, you get the messages like "time to service your car" or "hey! check your engine".
• When you are driving, you get speed, fuel status, turn signal indicators, bright light indicators, etc. 
• You don't have to navigate somewhere else for additional information to do the task of driving.
• You don't get unnecessary information that is not actionable during the act of driving.

Dashboards are well suited to reducing information scatter, and they help manage information overload when skillfully designed. A key feature that is often overlooked is to pare away all unnecessary data elements (removing words that don't add value).  For example, "lisinopril 10 mg daily", and not "lisinopril 10 mg 1 tablet oral daily".

Why dashboards?

Dashboard views should be the rule rather than the exception in EHR design
Physicians and nurses have to deal with complex data involving a number of realms, making quick judgments based on the overview of the patient's story.

Dashboards beat nested navigation in several ways:

1. They minimize navigation.
2. They reduce cognitive load by presenting the needed information in a single view. 
1. Users don't have to think "What next? Where next? 
2. Users don't have to use visual memory to recall the last page view: "What was that potassium value I saw seconds ago? Was that drug dose once a day or twice day?"
3. Users can "scan the scene" to quickly see if there are any abnormals. If the view is "clean", then we can move on.
3. They accommodate a variety of workflow styles. Methodical  or meandering paths work equally well when only the eye (and not the finger) does the walking. ABCDE sequence is as easy as AEDCB.
4. They can be customized or personalized to meet unique user needs.

There are some caveats.

1. Provide only the information needed for the tasks at hand. No more, and no less. That may mean leaving out detail from the grand view, while making that detail available when drilling down.
2. Use visual cues. They don't have to be words. They do need to be recognizable at a glance. Think icons and traffic lights. 
3. Try the designs out on real world users.

Medications List - Visual Design Make-over

Some rights reserved by CarbonNYC

I'm reading "Designing with the Mind in Mind: Simple Guide to Understanding User Interface Design Rules" by Jeff Johnson. As a typography/layout and design geek, some things are obvious to me, but Jeff Johnson reminds me they are not obvious to everyone. He even makes explicit the cognitive psychology behind the "design rules" that have been gospel to designers.

I'll give his teaching a test drive here, starting with a design from a typical EHR.

Design Make-over - Step by Step

EHR Usability: An Illustrated Guide

I did a brief presentation at NIST on July13, along with about 2 dozen other usability geeks like me. The government recognizes the importance of having usable software if physicians and hospitals are to be expected to adopt electronic medical records. The ARRA incentives alone won't be sufficient if the software usability is lacking, causing physicians and other healthcare workers to lose productivity. They might break even, but many physicians worry that they won't, even with the financial incentives. Here are the pictures. You have to imagine my voice.

Belden nist 13_july2010 from Jeff Belden MD

View more presentations from Jeff Belden MD.

NIST will be posting the slides and audio later. You might try here.

AHRQ publishes paper - "EHR Usability: Vendor Practices & Perspectives"

AHRQ just published a new white paper last week.
You can read it here as a PDF.

From World Usability Day 2006 poster

The objectives of the project that led to this paper were:

...to understand processes and practices by these vendors with regard to:

• The existence and use of standards and “best practices” in designing, developing, and deploying products.
• Testing and evaluating usability throughout the product life cycle.
• Supporting post-deployment monitoring to ensure patient safety and effective use.

It's good to see continued attention to usability in the EHR/EMR world.

Personalizing User Preferences, within Guardrails

EMRs are complex applications.

No Joke.

Here's an example of a fairly typical User Preference Setting dialogs (with my annotations):

It's not always easy to find my way to the preference settings. They might be buried deep in a menu as "Options" or "Settings" or "Preferences". When I look at the options to check, it might be quite hard to understand what will happen if I check or uncheck an option.

Trainers and support staff have nightmares as a result of the complexity.

Offer users more flexibility and the troubleshooting is more complicated, but if users' initial settings are not "just right", then the application won't behave as expected.

How can we empower the physician or nurse user?

How can the preference settings be made more understandable and accessible?

How can we help users have an experience that is "right for them"?

One way would be to place the preference settings closer to where they have an effect (see mock-up image below).

• Make the range of choices smaller (The Simplicity Principle of Usability). 
• Make the range of choices "safer" (The Forgiveness Principle of Usability). Don't let me change things I might regret, and be unable to fix. Offer "personalization within guardrails".
• Put the choices close to the action ("Preservation of Context" and "Efficient Interactions" Principles of Usability).

I like to call this "just-in-time personalization".

The little "gears" icon  shows up whenever there a few user preference (or "personalization") settings.

Design Thinking

I've just started reading Tim Brown's book, "Change by Design: How Design Thinking Transforms Organizations and Inspires Innovation". It quickly had me thinking about innovations in EMR usability.

Design Thinking balances three values:

Desirability, Viability, and Feasibility.

[Tim Brown's illustration]

He describes desirability as meeting true human needs and desires, as opposed to the drummed up desires personified in perfume ads. On a global scale, these needs include clean water, adequate diet, good health, education for children, and a safe community.

What does "desirability" mean for EMR users?

Here are a few of my ideas. What ideas can you add?

Basic Needs & Desires for Physician and Nurse EMR Users

Rapid, easy, intuitive documentation

• We shouldn't have to type so much. Voice recognition is nearly there, but not mainstream. Voice capture for transcription embedded into the EMR is spotty.
• How about features like "auto-fill" used in e-commerce sites?
• How about "predictive fill" as we see now in Google's predictive search phrases as we start to type?

Smart displays of key information for the task at hand

• The information ought to be visible at a glance.
• No navigation should be needed.
• All the cognitive effort should be squeezed out of the information. Don't make me do mental math. Don't make me remember a rule, or a set of normal ranges. Leave my brain to do only the work that the computer cannot do for me.

Foster collaborative decision-making with patients and their families

• In the hospital, acute pain med doses are often negotiated ("That medicine made me nauseated last time. Can I have something else for pain?" or "Can I have a smaller dose, so I'm not so drowsy?") Give the nurse and patient the tools to decide together.
• In ambulatory care, physicians often explain and negotiate items like bone density scans or PSA blood tests. The guidelines recommend counseling for edge cases, like the most recent guidelines from the USPSTF for mammography for women age 40-49. Give physicians counseling tools that help patients (and doctors, for that matter) understand comparative risks. We do a poor job of that currently.

Enable user-level configurability

• Novices have different needs from more experienced clinicians.
• User preferences change over time. We learn. Make it easy to find and change preferences. Currently, these prefs are buried deep and are widely scattered.

How will these changes happen?