VA View Module 6: Usability and Human Factors

VA View Module 6: Usability and Human Factors

Introduction

[Janine Purcell, Human Factors Engineer]

My name is Jeanine Purcell and I am a Human Factors engineer. For over 10 years, I’ve worked in various national Patient Safety offices for the Department of Veterans Affairs.

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Human Factors

[Health Informatics 101: Module 6 Usability and Human Factors]

Human Factors Engineering and Usability Engineering are key to the patient safety approach in VA. People don't come to work to make mistakes. The patient safety movement includes the realization that we can design our work tools, environments, and organizations to be resilient to our inevitable mistakes so that they don't result in patient harm.

The focus in this Health Informatics 101 course includes optimizing the design of software tools by considering what our users need and want. We can consider the design of software from a progression of levels. We need to attend to very detailed elements such as the visual appearance of the screen. Moving up in complexity, we consider the design of screen content to fit information synching, data entry, and to optimize decision making tasks.

Beyond that, we can ensure that the flow of screens takes advantage of opportunities to order treatments and implement those treatments accurately and efficiently. Let me downshift for a second and talk about some concrete examples at the simple level of taking in information.

[1)Vision- Size (ABC appears on screen from big to small font sizes); Contrast (ABC appears on screen from dark to lighter contrast)]

First, vision. At a certain point, we all realize that items on the computer screen can be too small to be seen clearly, and for some of us as we grow older the need for larger fonts and other screen elements increases even beyond what might be needed for people that are younger.

Also, we need a certain amount of contrast in the colors that are between the background of the screen and the colors of the fonts on that screen. If these physical characteristics are suboptimal, we’ll perform slowly or even make mistakes.

What the human factors and usability bodies of knowledge bring to the table are guidelines and standards about these sorts of visual elements of screen design.

[2) Hearing (an image of a volume logo appears)]

In terms of hearing, if there are tones that are meant to alert us to information on the screen, those alerts need to be loud enough, persistent enough, and distinct enough to be heard in various settings in the hospital, such as noisy areas like intensive care units and emergency departments, laboratories, pharmacies, and operating rooms.

So, from a usability perspective, in order to ensure those warning tones are effective, they need to be validated in the actual environments of use, an approach this unit on usability engineering will cover.

[3)Cognitive Load (image of a human brain)]

Consider also, how we need to design to lessen the impact of limits in attention, memory, and cognition. People using healthcare information technology are interrupted frequently, work under time pressures, and are fatigued or stressed from the demands of work and personal life. All of these erode our capacity to pay attention, remember where we left off in a task, or correctly remember what we were intending to do. We're prone to mistakes in entering information, performing mental calculations, and projecting trends in physiological or other health data. The good news is that the design of our systems can support more accurate medical decision-making, and in the case of errors, reduce or eliminate their consequences to our patients.

[Automatic versus Controlled Processing]

Now, I’m going to briefly emphasize two general concepts important in patient safety and healthcare information technology. The first is automatic versus controlled processing. What I’d like you to do right now while you're watching me is just cross your arms. [presenter crosses her arms]

Now, cross your arms the other way. That takes a second, and you really have to think about it, because we all have a natural tendency.

There's one layering of our arms that we naturally go to. To reverse that, we have to slow down and become conscious of our actions. This is a really important element in how we design healthcare information technology. Sometimes we really have to snap people out of very automatic behavior, very practiced behavior, and bring them into the moment into conscious processing. I'll talk about an example in a little while.

[Speed Accuracy Tradeoff]

The other principle I’d like you to keep in mind is what's called the "Speed Accuracy Tradeoff." This is an important element of human performance. The bottom line is sometimes if we have to emphasize accuracy, we have to slow down. If we emphasize efficiency, we are going to lose accuracy. Again, I'll show an example soon.

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EHR Examples

[Examples: Changes in EHR to Improve Patient Safety]

Now I’m going to talk about a few examples of changes we made in our electronic health record to improve patient safety. The first example is from our barcode medication administration software. Its acronym is BCMA.

[Bar Code Medication Administration (BCMA)]

BCMA uses barcodes as a means to positively identify patients and to ensure correct medication administration. For medications such as pain relievers, a nurse has some discretion to give the medication as needed. However, there are still schedule limits as to how frequently the meds can be given.

[Screenshot of Original Medication log screen; screen zooms into the last four actions]

In the original design of this medication log screen, nurses did have some information about the last four actions that were taken in regard to this medication. But we were still seeing sometimes these medications being given too soon. In order to help nurses realize when it was too soon to give these medications, a work group including developers, nurses, pharmacists, and a human factors engineer set out to enhance the information on this screen to try to make the nurse more consciously aware of the time since the med was last given.

[Screenshot of Redesign of Medication Log screen; screen zooms into the schedule, last given information and acknowledge box]

You'll see in the redesigned screen, at the lower left hand corner of the screen, there's a little warning icon. Now, the schedule is actually listed. In this case it's every four hours as needed. There's also a computation of time since the drug was last given, in terms of hours and minutes. Lastly, there’s a checkbox that has to be checked, it acknowledges that the nurse reviewed the schedule and the last administration of the medications.

The nurse can't leave this screen unless the checkbox is marked. So, in this way the design was meant to bring the nurse into more conscious processing of the information. It also provides some decision support by showing the schedule, time, the schedule duration -- four hours, in this case-- and the computation of that time. The time elapsed since last time can be compared against the scheduled time again to help the nurse understand that maybe it's too soon to give the medication over again. We haven't been able to do a big quantitative data assessment of the impact of this, but we do know from anecdotal evidence that it has helped nurses in some cases realize that it was too soon and not to give these medications.

The next example has to do with a case in which it was very important that information be entered accurately. A number of years ago, the National Center for Ethics and the Department of Veterans Affairs determined that they wanted to move to a tool that would allow us to create electronic documentation of informed consent. In the beginning a very small number of hospitals had bought the software from a third party and the tool was very, very simple. In that tool where you designated the anatomical location and the side for the operation, right and left were in a drop down box.

It's really easy to pick the wrong item in a drop down box. And we knew that in order to increase the accuracy of the designation of the anatomical location, what's called laterality, it was very important again to use a data entry method that would be less error prone than things like drop down boxes.

So, what you see now in this example, [Screenshot of Informed Consent Software] this is how we persuaded and collaborated with that software vendor of this tool which is iMed Consent.

The screen where anatomic location and side are put in to the informed consent form, the user actually has to type it in in words. No picking from drop down lists or other choosing mechanisms in the user interface thing. They have to type it in. This is a case in which we don't go for efficiency by using a drop down list, but insist rather that the full words be typed in by the clinician.

The last example I’m going to talk about has to do with the redesign of the most recent view in the labs tab. Users had difficulty accurately interpreting the date of the lab test. Here's the screenshot [VistA CPRS Original Design - Most Recent Views in Labs Tab]of how this view originally appeared and how it was laid out.

EHR Examples (continued)

You'll notice that the date information[Screenshot of Original Design -- Location of Data Info] actually is up in the control area. It's away from the actual name of the test and the result value for the test. We had a case where a veteran patient actually had an unnecessary procedure because clinicians interpreted an old lab result as the most recent one.

We pursued several activities in the informatics patient safety office when it was determined that we would try to redesign the display and see if we got more accurate interpretation of results. In the first activity we brought eight users together and we actually hand them information in the test database, and real clinical scenarios. One of those scenarios replicated the case in which the patient had been harmed because of the misinterpretation of the date. We found in that scenario with these users that three of the eight misinterpreted the date information. We knew we had the possibility of redesigning this and getting more accurate interpretation.

We reconvened a second session, a joint application development session. Some users from the first session came and back and we had some new people in the mix. The developer was there and some Human Factors people, and also some Requirements Documentation staff. We used simple tools. We projected the test account data on a screen.

We used whiteboards to sketch out some redesign concepts, and actually the developer, to explore the feasibility of some of the changes, actually implemented them in the test database while we were at lunch that day. So, we went ahead and had the developer build in these changes in the test database and then we executed a formal usability test where we had users from two facilities, actual clinicians come and work in the test database again and see what the accuracy results were.

[Screenshot of Redesign - Location of Date info, Paging controls, and specimen type]

As you can see, in the redesign screen, we made some significant changes, well, not so significant small changes, but important changes. [Redesign - Location of Date info, Paging controls, and specimen type] We reordered the information so that the date was moved to be right next to the name of the lab result and we also made the buttons for manipulating the views from the oldest result, page through to the next, or jump ahead to the newest lab result. When we tested this, we first used a format where the date was listed next to every component of the blood result, and we did get 100% accuracy in this task of finding the most recent result.

However, we got feedback that because the date was next to every component of the lab result, users found themselves scanning down that column to make sure it was the same date down the whole panel, so we had an alternative design[Screenshot of Final Redesign - Location of Date info, Paging controls, and specimen type] which we tested where the date was only listed in the first line of the components for that set of results. We found that users were accurate with a single line of date information with this grid area, and also the majority preferred it because they weren’t going through that extra cognitive load of verifying the dates down the column. This is an example of how some small changes were made to an information display, and we actually have some performance data that showed that the redesign resulted in a more accurate interpretation of the information.

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Standards

The last point I want to touch on in this little lecture on this week’s content on usability has to do with standards relevant to usability and human factors engineering. Standards development organizations do have committees that work on human factors engineering standards, up to this point those standards have related to the development and design of medical devices. Those standards organizations are also extending and creating standards that will relate to health care software, which is standards terminology for health information technology.

[National Institute of Standards and Technologies (NIST)]

Also specifically in America, The National Institute of Standards and Technology (NIST) is developing an important body of work regarding usability and the electronic health record. NIST is working for the Department of Health and Human Services Office of the National Coordinator to produce this framework for electronic health record usability.

I am confident in the next few years VHA will increase our application of humanfactors and usability engineering methods to enhance the ability of our VAcaregivers to provide safe and effective care to our veteran patients. I also knowwe’ll work to provide usable and satisfying tools to our patients as theyparticipate more and more in the health care experience.

Thanks for spending this time with me and I hope you found this information inthis week’s lecture and in this module to be helpful as you move forward in yourhealth informatics work at VHA.

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