Control

Put Users in Control

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The “Users Are in Control” principle requires that the EHR should give users the impression that the system is completely controllable.

Users are initiators of, not responders to, actions. Actions should result from explicit user requests. A typical bad example that goes against this rule is the inappropriate use of AutoFill. As shown in the prescription page (see Figure 1.), when a physician fill in the drug Bicillin, other information regarding this drug such as quantity, medicine unites and the way of giving medication is automatically filled. However, these items may vary greatly according to specific patients in the clinical setting. The physician has to check every item and make corresponding corrections. This inappropriate use of AutoFill will bring inconvenience to users. A good design should provide users the option to turn on or turn off the AutoFill function.

Figure 1:

In this bad example, once the drug is filled, corresponding parameters are automatically filled. This inappropriate use of AutoFill functionality can lead to the feeling in the user that he\she is the responder to system actions.

In order to make users to be the controller, the EHR should avoid surprising actions or unexpected outcomes. When dynamically displaying information, the system should also provide informative information as well as associated controls to facilitate user actions. For example, when a clinician fills a number that is out of the normal range, a reminder should pop up for the user to decide to refill or ignore it. Figure 2 shows a typical bad example of this. As we can see the user fills the temperature with an extremely lager number. The “Save Form” button turns blue, which indicates the information cannot be saved. However, the system does not give any reminder of this. The user may feel confused about how to proceed.

an example of unexpected system response

Figure 2: In this bad example, the entered information cannot be saved due to the obviously incorrect entry of the temperature. But the system provides no explanatory information regarding this, which may make the user feel confused how to proceed.

Besides control to system actions, users should have control to their position and status within the EHR. This means users are able to go back or forward freely for their own needs. A good example of achieving this is the use of clickable navigation. For example, below, users can choose the part they want to finish or refer to by clicking the navigation panel on the left side (see Figure 3).

a good example of allowing users to control their position and status

Figure 3:

In this good example, the system provides a navigation panel on the left of the screen, which enables the user to control their position freely.

Users’ freedom to act out of their convenience is also an important aspect of “Users are in control” guideline. The EHR should provide user functionalities to control for convenience. For example, unit transition is common in clinical settings. A physician may prescribe one medicine in mg, while prescribe another in mg/1cc. Therefore the system should support selection of medicine units for different cases. Below is a bad example of this (see Figure 4). Medicine unit in this system is fixed at mg. If the physician wants to make prescription in other units, he has to do the conversion by hand. Clearly, this system does not give users convenient controls.

a bad example of providing the user functionalities to control for convenience

Figure 4;

In this bad example, the system fixes the medicine units in “mg”, which bring inconvenience when the user wants to enter in other units.

Guidelines summary:

Users are initiators of actors, not responders to actions.

User must control the interaction: System actions should result from explicit user requests.[3] CUI (Design Guidance - Recording Adverse Drug Reaction Risks) p. 15
Do not permit changes to measurement systems (e.g., lb vs. kg) unless initiated by the user. [4] NIST7865 IV-A p.22
Support updating information that is initially inaccurate or unknown (e.g., last names, sex, weight). [4] NIST7865 VII-B p.27
Provide access in context to further details on demand. [3] CUI (Design Guidance - Medications List) p.13
Support corrections to plotted data. [4] NIST7865 IV-K p.23
Support display and tracking of components of combination vaccines. [4] NIST7865 V-C p.24
Enable seeing where normal ranges originated from (adult normal, pediatric normal, weight-based normal, age-based normal, body surface area normal). [4] NIST7865 VI-B p.26

Avoid surprising actions, unexpected outcomes, tedious sequences of actions, etc.

When dynamically presenting information (such as status information, error messages or warnings), display the information in context and facilitate action where necessary by clearly providing associated controls. [3] CUI (Design Guidance - Drug Administration) p.21
Offer users direct access to high-priority tasks on the homepage. [1] Nielsen’s 53
Explanations should be available for any alert or preference. [3] CUI (Design Guidance Exploration - Decision Support) p.5
Mitigate the potential for action to be taken without sufficient information by presenting carefully selected information by default, avoiding occlusion and providing clear signposts to further information. [3] CUI (Design Guidance - Drug Administration) p.21
User must be able to easily access justification for expressions of future risk, where justifying information is available. [3] CUI (Design Guidance - Displaying Adverse Drug Reaction Risks) p.7
Notify users when multiple search options exist. [2] Usability.gov 17:7

Users must be able to control their position and status within system

User must be able to easily return to high-level information after viewing detailed information. [3] CUI (Design Guidance - Displaying Adverse Drug Reaction Risks) p.7
Use a clickable ‘List of Contents’ on long pages. [2] Usability.gov 7:3
Provide navigational options for users to control their progress (e.g. breadcrumb navigation). [4] NIST7865 IV-G p.23 Usability.gov 7:1
Allow users to see their entered data [2] Usability.gov 13:8

Provide user functionalities to control for convenience.

Design search engines to search the entire site and allow users to choose from simple or advanced search. [1] Nielsen’s 50 [2] Usability.gov 17:2
Clinicians work in time-pressured environments and may need to trade-off detailed reading and entry of notes against speed and efficiency. [3] CUI (Design Guidance - Recording Adverse Drug Reaction Risks) p. 15
Support documentation of incomplete medication information. [4] NIST7865 II-F p.18
Support custom formulations for liquid medications. [4] NIST7865 II-E p.18
Support the use of gestational age and corrected age for patient care (in addition to chronological age).[4] NIST7865 VII-C p.27
Support connecting prenatal data (e.g., fetal imaging procedure) with post-birth data. [[4] NIST7865 VII-E p.27
Support high-precision dosing for low-weight patients.[4] NIST7865 II-C p.27
Allow sorting of vaccination data by multiple fields. [4] NIST7865 V-E p.25
The full set of local decision support functionality will be provided when the user logs on. [3] CUI (Design Guidance Exploration - Decision Support) p.5

Please note:The content provided here are intended as guidelines (recommended, but not mandatory) for design and implementation, not as standards (mandatory, minimum requirements).

References:

[1] Nielsen J. 113 design guidelines for homepage usability. 2001; Available from:www.nngroup.com/articles/113-design-guidelines-homepage-usability.

[2] U.S. Dept. of Health and Human Services. The Research-Based Web Design & Usability Guidelines, Enlarged/Expanded edition. Washington: U.S. Government Printing Office, 2006. Available from: https://www.usability.gov/.

[3] Microsoft. Microsoft Health Common User Interface design guidance. 2012; Available to download from: https://archive.codeplex.com/?p=mscui. (Design Guidance - Find a Patient PDF).

[4] Lowry SZ, Quinn MT, Ramaiah M, Brick D, Patterson ES, Zhang J, et al. A human factors guide to enhance EHR usability of critical user interactions when supporting pediatric patient care. The National Institute of Standards and Technology; 2012.

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