Monday, December 23, 2013

Usability Driven Development of the User Interface of Health IT Systems

The following are examples of patient safety incidents that can occur when using an electronic medical record (EMR), a Computerized Physician Order Entry (CPOE), or a clinical decision support (CDS) system:
  • Incorrect identification of a patient resulting in the administration of the wrong drug.
  • Incorrect medication dosage due to a miscalculation of body weight resulting from a mix-up of kilograms and pounds.
  • Missing data or incorrect data entry into a patient's medical record.
  • Misreading of patient's medical record due to a font size that is too small on a computer screen.
  • Errors in medication dosing frequency due to a non-intuitive menu.
  • Incorrect test ordered due to a clinician clicking on the wrong test.
In this first blog post, I suggest a usability driven approach to gathering software functional requirements and designing the user interface of health IT systems. The goals of this approach are the following:
  • Increased patient safety.
  • Increased productivity of healthcare staff through a user-friendly, predictable, and intuitive interface backed by scientific research and validation.
  • Reduced need for staff training due to a consistent look and feel across clinical applications.


The NHS Common User Interface (CUI) Program

Since November 2004, the British National Health Service (NHS) Common User Interface (CUI) Program in collaboration with Microsoft has been creating standards and guidance in support of the usability of clinical applications with inputs from user interface design specialists, usability experts, and hundreds of clinicians with a diversity of background in using health information technology.

The program is based on a rigorous development process which includes: research, design, prototyping, review, usability testing, and patient safety assessment by clinicians. The NHS CUI standards and guidance have been tested in production through the NHS Summary Record Application (SRA) project. The Guidance Catalog covers the following subjects with high impact on patient safety:

  • Patient Identification
  • Consistent Navigation
  • Accessibility
  • Abbreviations and Acronyms
  • Clinical Noting and Terminology
  • Decision Support
  • Handover
  • Information Entry and Display
  • Medications Management.

Usability in the Design and Development Phase

As a best practice, formal usability testing should be conducted early in the design and development phase as opposed to doing usability assessments only after the application has already been developed and deployed into a production environment.
In my experience as a Health IT Business Analyst, creating a mockup for new Health IT software applications is a very efficient way of capturing functional requirements. Mockups are very useful in helping to communicate the vision of the Product Owner and can also be very helpful to the other project stakeholders like end users, testers, and developers. I use Balsamiq to create mockups that comply with CUI guidelines. Usability testing can be performed against these mockups to ensure CUI compliance and also to obtain early feedback from potential users of the system. I perform Usability Testing of the mockups with end users using a proven methodology like the System Usability Scale (SUS).

Twitter Boostrap Components in Support of CUI Guidelines

Twitter Boostrap is a very popular and powerful mobile-first front end development framework that supports the Responsive Web Design (RWD) approach to achieving cross-browser and cross-device capabilities. There are emerging tools that can assist in converting a Balsamiq mockup into Twitter Boostrap Templates. An example of such a tool is Napkee.

Microsoft has published a set of UI controls that implement CUI guidelines using Silverlight, a now defunct front-end framework. Twitter Boostrap on the other hand is based on open web standards and framework like HTML5, CSS3, and JQuery (a JavaScript library) and is supported by a very large community of web developers. The availability of open source Twitter Boostrap UI components that implement health IT usability guidelines could result in significant cost savings and increased patient safety.