Audio Transcript

Working with Health IT

Systems
Fundamentals of Usability in HIT
Systems—What Does it Matter?
Lecture a

Health IT Workforce Curriculum

Version 4.0/Spring 2016
This material (Comp 7 Unit 5a) was developed by Johns Hopkins University, funded by the Department of
Health and Human Services, Office of the National Coordinator for Health Information Technology under
Award Number IU24OC000013. This material was updated in 2016 by The University of Texas Health
Science Center at Houston under Award Number 90WT0006/01-00.

This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0

International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-
sa/4.0/.
Slide 1

Welcome to Working with Health IT Systems: Fundamentals of Usability in HIT

Systems—What Does it Matter? This is Lecture a.
In this unit we will present the basic concepts of usability in general, and HIT usability
specifically. Students will be exposed to usability bottlenecks and learn to identify
examples of usability roadblocks in the example EHRS lab system, while hypothesizing
potential downstream effects of poor usability. Students will be challenged to suggest
solutions or alternative designs. This unit will also detail the relationships between
usability, user satisfaction, and workarounds.
Slide 2

The Objectives for Fundamentals of Usability in HIT Systems—What Does it Matter?

are to:
• Define usability and its relationship to HIT systems
• Explain the impact of HIT usability on user satisfaction, adoption, and
workarounds including error rates and unintended consequences.
• Provide alternatives to HIT usability bottlenecks
In this unit we will begin with general descriptions and definitions of usability, and then
apply those concepts to Health IT systems.
Usability has a tremendous impact on the user experience and can also impact
satisfaction and levels of acceptance of a system. Poor usability can also engender
workarounds, increase error rates, and generate unintended consequences or effects
that were unexpected. By the end of this unit, you will be able to explain how Health IT
usability can effect each of these.
Finally, our goal is not only to increase your sensitivity to the challenges of Health IT
usability, but to also help you to be able to suggest alternatives to Health IT usability
bottlenecks. It is one thing to critique usability – but as a health IT professional, you
should be able to suggest alternatives.
Slide 3

Usability is defined by the ISO as “the extent to which a product can be used by
specified users to achieve specified goals with effectiveness, efficiency, and satisfaction
in a specified context of use.” You will note that the ISO is not talking about computer
systems specifically. Usability is applied to any “product.”
For example, did you know performer John Denver’s plane crashed in the late 1990s
because of a faulty design that required that he turn around, in the pilot’s seat, reach his
right hand over his left shoulder, in order to either shut off his fuel lines or switch from
an empty tank on one side to a full tank on the other? The way the aircraft was
designed also required that he let go of the controls and reach behind his shoulder to
find the valve and turn it.

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As the National Transportation and Safety Board (NTSB) discovered, it was difficult to
do this without the pilot significantly bracing himself with his right foot to get the torque
necessary to twist in the seat and reach the switch behind his shoulder. Unfortunately,
the right foot area is where the rudder is located. And that's what killed John Denver.
Flying at a low altitude over the ocean beach in California, he went to switch the fuel
tank over, and braced himself with his right foot. It is hypothesized that he jammed his
foot full down on the rudder, which explains why his plane was seen veering sharply to
the right and plunging into the ocean. The eye witness reports were consistent with the
NTSB's reconstruction.
Dictionaries define usability as the study of the ease with which people can employ a
particular tool or other human-made object to achieve a particular goal. Obviously John
Denver did not find the fuel tank switch over to be easy … with tragic consequences.
The Denver tragedy illustrates an unintended consequence of poor design.
Slide 4

Jakob Nielsen, one of the foremost experts on usability, asserts that usability is a quality
attribute that assesses how easy a user interface is to use. As noted earlier, an
interface can be anything from the dashboard of a car, to the handles on a door, to the
layout of a computer screen. We can all pull to mind, rather easily, examples of poor
usability.
According to Usability.Gov, usability is defined by five quality components, but Jakob
Nielsen adds a sixth. The five start with Learnability.
Learnability is conceptualized as how easy is it for users to accomplish basic tasks the
first time they encounter the design. In short, how easy is it to learn? How easy is it for
a user to accomplish a basic task the first time she touches it?
Efficiency is related to the quickness (after learning the basic use of the system) that
users can perform the tasks. Does ordering a medication take 6, 8, 10 clicks? If so,
that may not be efficient.
The memorability concept is related to the ease experienced by a user returning to a
system or a product after a period of not using it, and reestablishing proficiency. You’ve
often heard once you’ve learned to ride a bike, you’ve learned to ride a bike.
Memorability is very, very similar. If you have been away from the device for a while
and you come back, how quickly can you pick back up your skills?
The fourth quality component is error and it is represented as observations,
experiences, and measurements of how often, what kind, and when the users make
errors while using the system. How severe are those errors? Are these life-threatening
errors, or just a nuisance? How easily can a user recover from the error is another
dimension of usability quality.
Satisfaction is a measure of how pleasant the design, the product or the system is to
use.

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The sixth piece—which is added by Dr. Nielsen—is utility, and that refers to the design's
functionality. Does it do what the users need it to do? Usability and utility are equally
important. It matters little
that something is easy to do if it's not what you need the system to do. It's also no good
if the system can hypothetically do what you want, but you can't make it happen
because the user interface is too difficult.
Slide 5

Think about those 6 components. Let's take error recovery as an example. Are
messages like these shown on the screen particularly helpful to a user? First off —in
that display on the bottom of the slide—using the words “FATAL ERROR” may not be
the best choice of words, but particularly in healthcare! Look at the error example at the
top of the slide. Besides the fact that the error message is stupid, a well-designed
system will give the user instructions of what to do next, which, other than “Close
Window,” the example at the top fails to do. What the message does tell the user is that
this is “the generic notification box”—and then informs the user “You should not be
seeing this box.” What would be your response if you were the user who received this
message?
Between the nonsense messages and the dead end in regards to how to proceed, this
type of message is what frustrates users. A good error message instructs the user how
to recover from the error, or how to prevent it from occurring again and gives the user a
message that can be interpreted. When usability decreases, frustration increases. With
increased frustration comes many other “side effects” that can increase error and
reduce willingness to adopt health IT.
More about this shortly. Let’s return to the ISO.
Slide 6

Think about those 6 components. Let's take error recovery as an example. Are
messages like these shown on the screen particularly helpful to a user? First off —in
that display on the bottom of the slide—using the words “FATAL ERROR” may not be
the best choice of words, but particularly in healthcare! Look at the error example at the
top of the slide. Besides the fact that the error message is stupid, a well-designed
system will give the user instructions of what to do next, which, other than “Close
Window,” the example at the top fails to do. What the message does tell the user is that
this is “the generic notification box”—and then informs the user “You should not be
seeing this box.” What would be your response if you were the user who received this
message?
Between the nonsense messages and the dead end in regards to how to proceed, this
type of message is what frustrates users. A good error message instructs the user how
to recover from the error, or how to prevent it from occurring again and gives the user a
message that can be interpreted. When usability decreases, frustration increases. With
increased frustration comes many other “side effects” that can increase error and
reduce willingness to adopt health IT.

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More about this shortly. Let’s return to the ISO.
Slide 7

So how can we take that abstract ISO model and translate it into the real-world of health
and healthcare? It is a six-step iterative process, which really never ends. UCD requires
that you study people in their own environments so you can understand how people
deal with specific problems and tasks in the process of interacting with the system.
The third step is developing prototypes of new technology solutions or new ways of
dealing with a process and then piloting—or field-testing—those prototypes, which is
very important so that you can work with your users to see how the new approach
works. This stage requires absolute humility—you must listen carefully to your user
base and then iteratively redesign until an optimal design is achieved.
Now remember, do not confuse optimal with perfect! There are limitations and the best
way to please nobody is by trying to please everybody. The prototype is redeveloped
into the next version, deployed, evaluated—and then the whole process starts over
again. It is an iterative cycle—particularly in the world of HIT.
Slide 8

Change, change, change, change. The philosopher Heraclitus said, “There is nothing
permanent except change.” In this world of HIT change is just constant. You are either
part of the future or you are history, so just get used to designing, listening, fixing—then
designing all over again, listening all over again, and fixing all over again. User
Centered Design requires it.
Slide 9

Let’s go a bit deeper in regards to usability and its relationship with Health IT. Think
back to that graphic on user-centered design a few slides ago. Remember, we must first
study and try to understand the user base (those were the first two steps).
Stepping into healthcare—what do we know about our user base in regards to clinical
computing? Well first we know that docs, nurses, pharmacists, other members of the
team are highly mobile workers who are operating in highly disruptive and stressful
conditions. They are distractible and in intense cognitive overload. We know from the
literature, public press, and common sense that overload, interruptions, and distractions
increase the chance of all types of error. The knowledge of the impact of distraction on
human error is one of the reasons that many states have outlawed talking on cell
phones that are not hands-free and prohibit texting while driving.
Further complicating the lives of our users, the Health IT users, are the restrictions of
physical space and restricted freedom of movement. Crowded rooms, impeding
furniture, visitors, equipment, these things all make maneuvering very much of a
challenge in health care. This is what contributes to the importance of non-intrusive
portable or mobile technology for busy clinicians. Interruptions in workflow that are
encouraged by fixed computing devices located in areas not convenient to the user
base—such as at the nurses’ station—contribute to efficiency losses, workarounds, and
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higher error rates. The “I’ll chart later phenomenon” results in latency of important data
being available to guide care. Even portable devices such as computers on wheels
(COWS or cows) are not a panacea. Studies are showing that cumbersome COWS are
frequently left in hallways or nursing stations so that they can be plugged in for a
recharge, are too heavy and clumsy to push and take into a patient room, or are too
time consuming to disinfect between patient rooms. Usability is a real challenge in
healthcare!
Also, the rate of turnover is really high—of both patients and staff—particularly in
teaching institutions where students are rotating constantly. This is an incredible
challenge in keeping people trained and competent as new versions of the software are
released, and the staff is constantly full of new faces. This calls for (remember back to
those 6 components of a usable system from a few slides ago) a system that is easy to
learn, easy to remember, error tolerant, helpful, and so on.
We also know from the literature that workarounds circumvent built-in safety features—
therefore we end up with results like in an article from Ross Koppel and colleagues
where the bar code administration system—purchased to reduce medication errors—
actually facilitated new types of medication administration hazards. As Koppel et al.
stated, we need to “understand how BCMA systems are actually used in the challenging
reality of hospital practice, why BCMA workarounds are so common, and what hospitals
can do to find them and to address their causes and unintended consequences.” That
comment is from page 421 of the Koppel article that you will find referenced at the end
of this unit.
Slide 10

This concludes Lecture a of Fundamentals of Usability in HIT Systems—What Does it

Matter? In summary, we defined usability and we discussed several consequences of
poor usability such as workarounds, error propagation, and unexpected and unintended
consequences.
The six quality attributes of usability (Learnability, Efficiency, Memorability, Errors,
Satisfaction, and Utility) were presented and described. Can you recall the differences
between each of them? Can you reflect on what relationship each of these terms has to
usability?
The ISO’s representation of UCD was provided as a model and the point was made that
UCD requires the study of people in their own environments. This, in turn, deepens the
designer’s understanding of how people deal with specific problems and tasks as they
interact within the work context. In relation to UCD, the importance of field-testing,
observing, listening, and then redesigning was emphasized.
Finally, the challenges faced by busy clinical users such as cognitive overload, constant
mobility, stress, and frequent interruption were presented, emphasizing the importance
of usability and applying several of the six quality attributes of usability.
Important points from this lecture are that the principles of usability are relatively
straight-forward and understandable—yet many systems today continue to be built
ignoring them. When poor usability is combined with busy and distracted clinical users,

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error is bound to occur. Having knowledge of these basic principles, designing with the
user in mind, and then testing and rebuilding until the product
is optimized are crucial to health IT that is both usable and safe.
Slide 11 (Reference Slide)

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Slide 12 (Reference slide)

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