Computers, Medicine, Usability, viewed from the ED
If you're new here, you might like to look through this introduction to the site first.
Are you interested in how computers can reduce medical error?
Did you know that many early medical computer systems increased medical error? (Some current ones, too.)
From your own experience with your own computer at home, do you think that some computers and programs crash on a regular basis? Do you think that most software is hard to use, rude, and frustrating to work with? Based on experience, what you’ve heard, or simple extrapolation, do you suspect that medical computer systems are even worse?
Did you know that the best place to test medical computer systems is the ED, because people working in the ED don’t have the time to deal with bad computer systems, and are intolerant of BS? (If it works in the ED, you can make it work anywhere else in the hospital.)
Do you want to learn more about how to make medical computer systems usable, so as to prevent medical error?
If the answer to any of these questions is “yes,” then read through the Medical Computing series. Although looked at from my viewpoint in the ED, it all applies to medical computer systems wherever they are used, in a hospital, in a clinic or in an office.
If you need a backgrounder on Healthcare IT concepts and terminology, see Healthcare IT in a Nutshell.
There’s also a series of “word” essays that focus on particular and generally more advanced medical computer issues.
To keep up with new postings, you might want to subscribe to my RSS feed.
One final note: Once explained, most of the suggestions on this site seem simple and obvious. But as one is creating a program, or even as one is using a program with a high level of frustration, they are still not obvious until pointed out.
I hope you find the site informative and, perhaps, a bit mind-expandingly entertaining.
Keith Conover, M.D., FACEP
An experimental study recently (late 2011) ballyhooed in the press looks at how we tend to forget things as we move into a doorway, and that walking back into the room doesn’t help you recover the memories. (Duh. I could have told anyone this. As could everyone.) Not sure why prior studies on the same topic haven’t been so widely reported. And does this have something to do with the fact that those with Parkinson’s Disease get stuck in doorways?
We get another heuristic (rule of thumb) for usability: “The more pages or dialog boxes a user has to traverse to accomplish a task, the less likely they are to remember what they were thinking at the beginning.”
In settings where distractions are rife, this effect is more likely to result in error, as you don’t have the cueing of the original screen to remind you where you were. The high degree of interruptions in the Emergency Department is a classic example.
Therefore, for applications for such environments should use techniques such as breadcrumb trails.
Again, duh. But the point is that the transition from page to page, or page to dialog box, is the transition where most of the forgetting occurs.
This entry was posted by kconover on Wednesday, November 23rd, 2011 at
9:51 am and is filed under
Tutorials .
You can follow any responses to this entry through the
RSS 2.0 feed.
You can skip to the end and leave a response. Pinging is currently not allowed.
Here’s another recent experience of mine with dialog boxes. The charting program DocuTAP recently was “upgraded” and now it pops up a dialog box for any abnormal vital sign – even weight and height. Or for a heart rate of 59. For example, when you click on a patient, the dialog box might say “Heart rate appears low. Please verify. If correct, please address possible reasons for a decreased pulse rate. PRESS ‘YES’ TO ACKNOWLEDGE THIS MESSAGE.”
This is a particularly frustrating dialog box, not only because it appears so often, but because, frequently, when you’re looking at the dialog box, you CANNOT see the patient’s vital signs to see how out of whack the pulse (or weight, or height) might be.
Wouldn’t it be better to, perhaps, highlight the pulse by making it red? (And, for those who are color blind, bold as well.)
And, if you click on a name while the nursing staff is entering vital signs, you may get an error message dialog box such as:
“Heart rate appears low. Please verify. If correct, please address possible reasons for a decreased pulse rate. PRESS ‘YES’ TO ACKNOWLEDGE THIS MESSAGE.
Weight appears to be low or not recorded. Please verify entry. If entered correctly, provider should address if clinically appropriate for this visit.
Systolic BP appears to be low. Please check that it has been recorded properly. If accurate, provider should address during the clinical evaluation.and recommend appropriate follow up if needed.[sic]
Please verify the patient’s height is entered correctly. Height can be a measured or stated value.
Diastolic BP appears to be low. Please check that it has been recorded properly. If accurate, provider should address during the clinical evaluation.and recommend appropriate follow up if needed.[sic]”
Please note that this dialog box is not aimed at the nursing staff, it’s aimed at me, the doctor! I think this wins some sort of award for the most verbose meaningless dialog box I have ever seen.
The Pennsylvania Chapter of the American College of Emergency Physicians (ACEP) held an international symposium on ED computer systems, November 12-15 in Miami. This was the fifteenth year for the conference. The focus was on how to effectively and efficiently use computer technology for ED process improvement. There were attendees from the 6000-bed Chang Gung Memorial Hospital in Taipei, and from the UK. Reviews from the attendees and from the vendors seemed quite positive. In 2009, there was no conference due to the worldwide recession. The 2010 conference’s attendance was below projections. There are various theories as to why this was so: the continued economic slump, the transition in many hospitals to being forced to use the ED module of an enterprise system rather than a niche system, and others. Regardless, PaACEP has determined not to offer this conference in the future.
A well-respected and very easy-to-use set of medical calculators (slanted to the ED) is available at mdcalc.com. Graham Walker set this up when was a third-year medical student and continued to upgrade and expanded it while an emergency medicine resident at St. Luke’s-Roosevelt Hospital Center in New York City. A consortium of emergency medicine residents and attendings affiliated with St. Luke’s-Roosevelt Hospital Center have also developed a companion website, an extremely user-friendly front-end to the evidence-based practice of medicine called thennt.com. (NNT is the “number needed to treat” and is a useful measure of how many people you have to treat to have a good effect on one person.)
The Emergency Informatics Association was founded a few years ago. It’s an association of both academics and vendors deeply involved in the nuts and bolts of emergency department informatics.
KLAS is a consulting company that studies healthcare IT in general. They do review and provide a bit of information on their website for free, but most of the opinion-poll information they gather, which is quite extensive, is available in reports costing $5-10,000. I have heard from a usually reliable source that some of the companies that big HIS vendors they review (examples of big HIS vendors include Epic, Meditech, Cerner) have contracts such that no employee of the hospital is allowed to say anything negative about their product. If true – and given the past conduct of HIS vendors, as reported at the EDIS over the past fifteen years, it seems likely – this makes ratings of such HIS vendors suspect. Recent gains in the rating of HIS vendor’s ED modules compared to the “best of breed” do, however, to some degree reflect a genuine improvement of the HIS ED modules in general.
Here’s another recent experience of mine with dialog boxes. The charting program DocuTAP recently was “upgraded” and now it pops up a dialog box for any abnormal vital sign – even weight and height. Or for a heart rate of 59. For example, when you click on a patient, the dialog box might say “Heart rate appears low. Please verify. If correct, please address possible reasons for a decreased pulse rate. PRESS ‘YES’ TO ACKNOWLEDGE THIS MESSAGE.”
This is a particularly frustrating dialog box, not only because it appears so often, but because, frequently, when you’re looking at the dialog box, you CANNOT see the patient’s vital signs to see how out of whack the pulse (or weight, or height) might be.
Wouldn’t it be better to, perhaps, highlight the pulse by making it red? (And, for those who are color blind, bold as well.)
And, if you click on a name while the nursing staff is entering vital signs, you may get an error message dialog box such as:
“Heart rate appears low. Please verify. If correct, please address possible reasons for a decreased pulse rate. PRESS ‘YES’ TO ACKNOWLEDGE THIS MESSAGE.
Weight appears to be low or not recorded. Please verify entry. If entered correctly, provider should address if clinically appropriate for this visit.
Systolic BP appears to be low. Please check that it has been recorded properly. If accurate, provider should address during the clinical evaluation.and recommend appropriate follow up if needed.[sic]
Please verify the patient’s height is entered correctly. Height can be a measured or stated value.
Diastolic BP appears to be low. Please check that it has been recorded properly. If accurate, provider should address during the clinical evaluation.and recommend appropriate follow up if needed.[sic]”
Please note that this dialog box is not aimed at the nursing staff, it’s aimed at me, the doctor! I think this wins some sort of award for the most verbose meaningless dialog box I have ever seen.