Compilation Results

Guidelines Compilation Results

Search results of guideline publications

The search returned 25 articles from Medline. After reading the title and abstract of each article, none of them were considered a potentially relevant article regarding the informatics system design in the field.

The search identified 23 documents by Google and Google Scholar, and the experts suggested two extra documents potentially relevant. Most of them were white paper or industrial documentation. The majority of them were lacking of explanations with respect to the validation process. After skimming the full documents, low reliable articles were excluded. They were either individual’s rules of thumb or reorganization of established guidelines based on the trustworthy sources. Eventually, four documents were selected to retrieve guideline items. They were from four reliable sources of Nielsen Norman Group, Department of Health and Human Services (DHHS), NIST-7865 and Microsoft Common User Interface (CUI).

Table 1, general features of qualified guideline documents

Publish year

Title

Author Descriptive granularity

Domain

Volume

Methods of development

2001

113 Design Guidelines for Homepage Usability [1] Nielsen Low

General

26 categories 113 guidelines Empirical study based

2006

The Research-Based Web Design & Usability Guidelines [2] DHHS Low

General

209 guidelines Expert review

2012

Microsoft Health Common User Interface Guidelines [3] Microsoft High and low

Health

33 categories with thousands guidelines Expert review

2012

A Human Factors Guide to Enhance EHR Usability of Critical User Interactions when Supporting Pediatric Patient Care [4] NIST High and low

Health

9 categories of recommendations Expert review

Matching results on usability principles

All principles from four document sources were tabulated in a format as shown in Figure 1. In the table, they were characterized mainly by five aspects of MU objectives, sequence ID, principle summary, source document and access hyperlinks. The numbered parts of principle summary are internal index in the document that helps locate related descriptors. As for the records without such index such as the principles from Microsoft CUI, the hyperlink of the specific piece of the document provides for easy access.

During the matching process, the curators had two tasks. One was to justify the relevance of the principle to EHR design with color codes. Green meant the principle was applicable; red meant inapplicable and yellow was uncertain. The second task was to match the principle up with MU objectives one by one. Two most appropriate MU objectives were labeled with the record in the table. Furthermore, each record was duplicated into additional spreadsheets by MU objectives. If one record could fit in more than four MU objectives, it eventually was put into an independent category as a general principle. Label inconsistency was resolved on a basis of group discussion.

Figure 1, the table structure of compiled guidance principles

the table structure of compiled guidance principles 

In the end, 303 principles were identified as applicable to the design of EHR and 133 of them were general. As for the rest 170 principles, they were designated to eight categories of MU objectives as shown below. Although we tried to assign principles to the categories exclusively, around half of them were cross labeled. Table 2 shows the distribution of principles by MU objectives, and Table 3 using e-prescribing as an example illustrating how assigned principles to be organized under each category of MU objectives.

Table 2, the distribution of principles by MU objectives

MU objectives

# of principles that fitted into this category

Medication list

8

Drug-drug and drug allergy interaction checks

25

Medication allergy list

25

E-prescribing

55

CPOE

64

Clinical decision support,

12

Electronic medication administration record

13

Clinical information reconciliation

45

As shown in Table 3, the majority of principles has numbered parts under the column of principles. They are locators for retrieving the principle details in the corresponding source document. As for the principles extracted from Microsoft CUI in which this information is not available, we attached the hyperlink to each of them that indicates in which specific file the principle was found. To interpret number parts of principles from the other three source documents, the rules are listed as below:

  • DDHS – the format of numbered parts is (A B:C) – A is the page number, B is the chapter number and C is the section number
  • 113 Nielsen – the format of numbered parts is (A) – A is the sequence number
  • NIST-7865 – the format of numbered parts is (A) – A is the sequence number in a aggregated table of guidelines in the document

Table 3, the aggregation of guidelines with respect to e-prescribing

ID

Principles

Source Docs

113 121 13:1 Distinguish required and optional data entry fields

DHHS

114 123 13:3 Label data entry fields consistently

DHHS

115 123 13:4 Do not make user-entered codes case sensitive

DHHS

116 124 13:5 Label data entry fields clearly

DHHS

117 125 13:6 Minimize user data entry

DHHS

118 126 13:7 Put labels close to data entry fields

DHHS

119 127 13:8 Allow users to see their entered data

DHHS

120 128 13:9 Use radio buttons for mutually exclusive selections

DHHS

121 130 13:11 Anticipate typical user errors

DHHS

122 131 13:12 Partition long data items

DHHS

124 134 13:15 Use check boxes to enable multiple selections

DHHS

125 135 13:16 Label units of measurement

DHHS

128 138 13:19 Place cursor in first data entry field

DHHS

130 140 13:22 Use data entry fields to speed performance

DHHS

131 140 13:23 Use a minimum of two radio buttons

DHHS

135 71. Use dropdown menus sparingly, especially if the items in them are not self-explanatory

113 Nielsen

136 24. Only use imperative language such as “Enter a City or Zip Code” for mandatory tasks, or qualify the statement appropriately

113 Nielsen

192 IIA. Protect against mode errors for mg/kg dosing and ml dosing.

NIST-7865

193 IIB. Flag that an intended dose is unusual.

NIST-7865

194 IIC. Support high-precision dosing for low-weight patients.

NIST-7865

195 IID. Do not permit automated defaults to adult doses.

NIST-7865

196 IIE. Support custom formulations for liquid medications.

NIST-7865

197 IIF. Support documentation of incomplete medication information.

NIST-7865

198 IIG. Reduce displayed options for medication orders.

NIST-7865

199 IIH. Display the recommended dose range for the selected mg/kg dose.

NIST-7865

200 III. Display “input masks” for data entry to clarify type of data.

NIST-7865

201 IIJ. Avoid truncation of medication names and dosages in menus.

NIST-7865

202 IIIA. Support flexibility in unit-based settings for alerts, reminders, and warnings based upon weight, height, Body Surface Area, Body Mass Index, and age.

NIST-7865

203 IIIB. Do not permit replacing pediatric-specific thresholds with default adult-based thresholds following a system-wide crash.

NIST-7865

204 IIIC. Do not permit “hard stops” for changes to medication orders.

NIST-7865

205 IIID. Cap the dose at the standard adult dose and allow override with justification.

NIST-7865

206 IIIE. Display normal ranges for medication doses and lab values based upon weight, height, Body Surface Area, Body Mass Index, and age information.

NIST-7865

207 IIIF. Display together parameters that are continuously monitored to rapidly intervene.

NIST-7865

242 Highlight the primary functions to support accurate recording of what happened for an administration event

Microsoft CUI

243 Display safety critical elements to the clinician without requiring user action

Microsoft CUI

244 Promote the primary functions to support quick recording of an administration event

Microsoft CUI

245 Support access to secondary functions without introducing screen clutter

Microsoft CUI

246 Transfer key design principles from the paper drug charts studied to reduce the need for training and increase familiarity when users move to electronic systems.

Microsoft CUI

247 Provide a visually-rich chart of information relevant to, and prioritized for, the administration of drugs

Microsoft CUI

248 Support the presentation of drugs with different characteristics (such as Significant Duration, Once Only or As Required drugs) within one view

Microsoft CUI

249 Display sufficient information for an accurate interpretation of the administration schedule(past, current and planned) and status of administration events within a relevant time interval

Microsoft CUI

250 Restrict the display of unnecessary information to reduce clutter and prioritize the information most likely to require action

Microsoft CUI

251 Provide access, in context, to further details on demand

Microsoft CUI

252 Mitigate the potential for action to be taken without sufficient information by presenting carefully selected information and explicit labels to clarify what information is displayed and the extent to which it is complete

Microsoft CUI

253 When dynamically presenting information (such as status information, error messages o warnings), display the information in context and facilitate action where necessary by clearly providing associated controls

Microsoft CUI

254 Support efficient and accurate recording of administration events with enough flexibility for differences in drugs and working practices

Microsoft CUI

263 Mitigate the risks of mis-selection and misinterpretation

Microsoft CUI

264 Increase efficiency by prioritizing the prescription of commonly prescribed medications over less commonly prescribed medications

Microsoft CUI

265 Maximize safety in the absence of decision support systems by designing for the reduction of errors from invalid or inappropriate selections or entries

Microsoft CUI

266 Encourage simplicity of design by promoting user interface approaches that help to avoid overly complex displays and interactions that require many controls

Microsoft CUI

267 Ensure that the prescribing process can be supported in multiple layouts and is flexible enough to be presented in different screen dimensions

Microsoft CUI

268 Maximize scalability such that the prescribing process can be modified to accommodate additional information, steps or shortcuts

Microsoft CUI

269 Manage users expectations and improve their efficiency by providing a clear framework with consistent logic for the placement of user interface elements and the interactions that they support

Microsoft CUI

270 Minimize the potential for important information to be hidden from view

Microsoft CUI

271 Adhere to a user interface strategy that gives the impression of making progress within a single space (that has all the necessary information immediately or readily available) and avoids the impression of needing to move between many different spaces

Microsoft CUI

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.

SHARPC Logo