Increased amounts of data contained in electronic health records (EHRs) have led to inefficiencies for clinicians trying to locate relevant patient information. Automated summarization tools that create condition-specific data displays rather than current displays organized by data type and time have the potential to greatly improve clinician efficiency. Methodologies for modeling and summarizing complex chronically-ill patients’ electronic health records were designed. Knowledge bases include:
This Editor can create computer-readable healthcare knowledge artifacts (in xml format) based on the formal HeD knowledge model. The goal is to enable a subject matter expert with little or no programming experience to create a knowledge artifact such as a decision rule without technical support.
Demonstration prototypes were produced for several EHR related situations that can be problematic in visual display. These include:
The reconciliation Algorithm which computes similarity between drugs is freely available at https://github.com/jherskovic/MedRec
To improve our understanding of the potential for EHR induced errors, seven commercial EHR products have been evaluated following the Rapid Usability Assessment (RUA) created at SHARPC. Our protocol, combining heuristic evaluation and keystroke level models of expert use, was used to identify usability problems that occurred during the completion of 12 meaningful use-related test procedures (e.g. CPOE for a medication order, updating of allergy lists). The identified usability violations were then scored for their potential for harm using a severity score and grouped according to test procedure. Confidential reports were provided to the participating vendors to help improve the usability of their EHRs.
The 2014 EHR Safety Enhanced Design requirements for testing and reporting of system usability also exposed need for validated, contextually-rich, scenarios for testing. As part of SHARPC efforts we developed assessment materials and detailed our methods for generating these materials as part of a call for open discussion regarding public exchange of protocols. Our hope is that scenarios used in testing capture the needs of clinical providers, robustly measure the usability of systems and provide a means of identifying safety risks in existing systems. These materials were written to support vendors engaged in usability studies and certification procedures. Included are participant instructions, moderator guides, standard usability scales and other materials included in user testing.
The SIRSI Cognitive Support System prototype facilitates the organization of clinical data in accordance with decision models derived from domain experts. It includes a back-end interface to clinical data sources, a knowledge module that can be interchanged depending on the decision model of interest, and iPAD and browser based interfaces through which clinical data can be viewed organized in a manner conducive to decision making related to the Systemic Inflammatory Response Syndrome (SIRS) in an ICU context.
Systematic Yet Flexible Systems Analysis (SYFSA) is a framework developed by SHARPC for designing and analyzing SYF systems. It is based on analyzing a task using three related problem spaces: the idealized space, the natural space, and the system space.
SHARPC developed a framework of EHR usability, called TURF, to unify the concepts and methods around EHR usability. TURF is (1) a theory for describing, explaining, and predicting usability differences; (2) a method for defining, evaluating, and measuring usability objectively; (3) a process for designing built-in good usability; and (4) a guideline for developing EHR usability standards. TURF defines usability as how useful, usable, and satisfying a system is for the intended users to accomplish goals in the work domain by performing certain sequences of tasks. One of the contributions of the TURF framework is to show that usability can not only be defined scientifically under a coherent, unified framework, it can also be measured objectively and systematically. Part of the TURF framework has been implemented as a software tool that is described in the next section.
Many of the techniques for usability assessments have included pen and paper along with stand-alone recordings. To aid in usability evaluation as well as testing and design of electronic health record systems, we have developed the Turf software, which is based on the TURF framework of EHR usability. Turf is a software tool designed to evaluate, document, and assist in improving EHR usability.
To determine whether these products were helpful to EHR vendors and to identify any additional vendor needs, SHARPC engaged a liaison to interview vendors. Their feedback showed that vendors without human factors design experts desired short, actionable advice to improve their EHRs in preparation for the safety enhanced design certification. It also revealed an inconsistency in how vendors viewed usability or user-centered design, with some thinking that it simply meant responding to user feedback. Findings suggested that, in addition to short design tips, vendors could benefit from pointers to more in-depth material on EHR user interface design. To address these needs, we developed a set of one-page safety enhanced design briefs (SEDB) along with a corresponding website for dissemination of the briefs and references to supplementary information.
Employing a systematic search methodology, SHARPC identified and compiled approximately 300 design principles from four major guideline documents that are significant to safety-enhanced and efficient design of EHR. These principles fall into 14 heuristic categories in terms of consistency, visibility, match, minimalism, memory, feedback, flexibility, messages, errors, closure, undo, language, control and help, illustrated with examples of DOs and/or DON’Ts. With the instruction of the categorized principles and examples, the guidelines should facilitate the design and development of EHR systems toward the objectives of meaningful use (MU).
SHARPC co-funded, with the California Healthcare Foundation, a clinically inspired, generously illustrated, interactive EHR (electronic health record) usability design guide targeted at the EHR vendor community, incorporating that group into its design and evaluation. Iterative feedback came from an expert advisory panel and the target audience.