and Usability
Work smarter, not harder.
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 duringdecades 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 namedThe 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:
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.
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 aNIST 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. TheTURF 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:
| Method | Description | Purpose |
|---|---|---|
| Card Sorting | A categorization method wherein users sort cards depicting various concepts into groups. | Card sorting helps developers organize a program's content. It helps them design better overall information architecture and better menus. It can also help physicians and programmers work together to effectively label a program's various functions. |
| Cognitive Walkthrough | A team of evaluations walk through a paper or working prototype, discussing the usability issues they encounter as they go. | This process helps identify additional application functions necessary for the tasks in a workflow process. |
| Exit Interview (Retrospective Think Aloud) | After a prior usability test, a moderator asks a user questions about how the system performed. | Provides meaningful qualitative information, as well as highlighting what's working, what's not, and why. |
| Focus Group | A moderator guides a discussion about the application being developed with a group of users. | Focus groups help developers understand the factors that affect individuals' relationship to the application’s needs and design. |
| Heuristic Evaluation (Expert Review) | Usability and design experts examine the product and determine whether it meets industry standards. | Experts who know key factors of good design and can quickly identify trouble areas, even subtle ones, that other methods might miss. |
| Paper Prototyping | Low fidelity usability testing of product concept made from paper or some simple tool. | Paper prototyping has a high value in the iterative design process. A design can be worked and reworked over and over again, especially when combined with cognitive walkthroughs, to quickly design a prototype. |
| Survey or Questionnaire | A survey or questionnaire asks specific questions about an application’s effectiveness or collects information about user demographics, preferences, and experiences with the tool. | Surveys can provide developers with feedback about a variety of design issues throughout the product's lifecycle. |
| Think Aloud (Concurrent) | Participants in testing express their thoughts on the application while executing set tasks. Think alouds are also used in an exit interview when the user is shown a recording of their session and asked to express their thoughts in retrospect. | This process can help gain insight into the thought flows of actual users as well as help answer questions about why users are performing tasks a certain way. |
| Usability Testing/Task Performance | Presents representative end-users with scenarios or specific tasks, designed to cover the major functionality of the software system and to simulate expected real-life usage patterns. | This process determines if the design works for the intended task or has gulfs between the user’s expectations of the design and the developer's concept of functionality. |
| Field Testing | Researchers evaluate products in the contexts in which those products would normally be used. | People use things differently in different settings. Collecting data in the field can provide new insights that are not always discoverable in a lab or test center. |
Health Information Management Systems Society (HIMSS)
EHR Usability Basics
HIMSS is a global, cause-based, not-for-profit organization that focuses on improving healthcare through improving and distributing information technology (IT). This site includes resources related to EHR usability evaluation and design.
National Institute of Standards and Technology
Health Information Technology / Usability
This site summarizes NIST's work on Health IT. It contains links to selected publications, and to records of NIST's conference proceedings. See in particular:
(NISTIR 7741) NIST Guide to the Processes Approach for Improving the Usability of Electronic Health Records
Strategic Health IT Advanced Research Projects (SHARP)
HealthIT.gov
SHARP's research works to address problems that impede the adoption of Health IT. See in particular:TURF EHR Usability Toolkit
Special Section of ACM Interactions (Nov/Dec 2011)
Edited by Harry Hochheiser and Ben Shneiderman, including
Usability.gov This is a valuable general resource on usability methods and principles.
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