Inspired EHRs: Designing for Clinicians


Health Information Technology
and Usability

Work smarter, not harder.

9.1 Usability

In layman’s terms usability refers to how easy or intuitive an interface is to use. Successful designers go beyond this vague notion of “user friendliness” and have a thorough understanding of their user’s community and the tasks they need to accomplish. They also use methodologies validated during decades of research on human computer interaction.

The International Standards for Human Computer Interaction (HCI) and usability (i.e., ISO 9241-11) define usability as the “effectiveness, efficiency, and satisfaction of a user performance within a specific context, such as physical and social environment.” But usability alone is not enough, an interface must also have good utility. Good utility means the interface provides the features needed to complete users’ tasks. Successful applications combine good utility and good usability.

Health Information Technology (Health IT) usability issues are similar to the information technology usability issues of other life-critical systems such as air traffic control or nuclear power plants. Users in all of these fields are experts in their domain, but they need rapid, error free information technology performance to do their jobs effectively.

Usability problem areas in an interface design might be indicated by workarounds, redundancies, or slow task completion, all of which could possibly lead to general user burnout. Health IT applications with usability problems are more than just annoying to use, they can cause serious patient harm (e.g. wrong medication or dangerous dosage, wrong treatment, missed results, wrong patient selection leading to a patient not receiving treatment and another receiving unintended treatment, etc.).

There is an art as well as a science to good interface design. Donald Norman’s seminal book: The Design of Everyday Things (initially named The Psychology of Everyday Things), highlighted the importance of balancing the imperatives of efficiency and aesthetics in the design process.

The 5 measures of usability are as follows:

  • Learnability: How easy is it for first time users to accomplish basic tasks using this system? How easily can users discover and access the system's more advanced features?
  • Efficiency: How quickly can users perform tasks using this system?
  • Memorability: If physicians stop using the system for some time, how easily can they re-establish their former proficiency with the system?
  • Errors: How many errors do users make while interacting with the system? How severe are these errors, and how easily can users correct them?
  • Satisfaction: How pleasant do users find their experience of interacting with the system?

The human factors chapter covers the large body of evidence from many different sources that illustrate the importance of usability. If an interface is difficult to use, people will simply not use it or experience a decline in productivity when they are forced to use it.

9.2 Methodologies

Usability is an increasingly important consideration in organizational and product planning. The good news is that there are many methodological tools that have been developed by researchers to aid designing and evaluating the usability of computer systems in general. More recently researchers have begun developing specific guidance for EHRs in particular.

Development methodologies such as contextual design help developers by offering validated processes with predictable schedules. Ethnographic, or user group, observation can guide task analysis and complement user participatory design processes. Writing scenarios help developer teams to build a common understanding of design goals. These scenarios can also help plan usability tests. Logs of current Health IT system usage can provide valuable data about task frequencies and sequences that lead to design refinements. These methods will provide the developers with valuable information about how the users go about their tasks and how frequently they perform various tasks. Armed with this information, the developers will be able to refine their designs.

Specific guidance for EHR design and evaluation is becoming more and more available. For example there is now a NIST publication that summarizes the rationale for an Electronic Health Record (EHR) Usability Protocol (EUP) and outlines a three-step process. These three steps consist of (1) EHR Application Analysis, (2) EHR User Interface Expert Review, and (3) EHR User Interface Validation Testing. The TURF Usability Toolkit developed at the University of Texas can help create, organize, and analyze usability of EHRs. Other Health IT and general usability and design resources are provided at the end of the chapter.

Usability evaluations provide developers with subjective and objective data for improving the user interfaces. For practical results, 5 to 8 people participating in a pilot study using most methods can already provide valuable feedback and suggestions for improvements. A group of sixteen to twenty participants will start to consistently report similar issues with the design. At this point, the developers can study these results and refine the design accordingly. The developers can run several testing cycles to make sure they address all the program's significant problems.

Other methodologies for evaluating or creating designs and evaluation include:

This book was last updated 10 Nov 2014.

The designs in this book were created by our team and reviewed by a national panel of clinical and human factors experts, but have not been empirically tested against existing designs.