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As many contributors to this forum have noted, the lack of usability of EMR software remains a major obstacle to its acceptance and widespread use. Just this month, The National Research Council reported that currently implemented healthcare IT programs often ‘provide little support for the cognitive tasks of the clinicians or the workflow of the people who must actually use the system. Moreover, these applications do not take advantage of human-computer interaction [HCI] principles, leading to poor designs that can increase the chance of error, add to rather than reduce work, and compound the frustrations of executing required tasks.’
(http://books.nap.edu/openbook.php?record_id=12572&page=R1 , page S-3).
I believe that there is a pressing need improve EMR software by taking advantage of what we know about how the human brain takes in, organizes, and processes information. I envision a user-centered EMR, simple, powerful, elegant, and built from the ground up on principles of interaction design. In this and subsequent threads, I would like to share for discussion and critique some ideas for improving EMR usability. I also look forward very much to discussing the insights and solutions of other forum members.
In this first thread, I would like to present a visual idiom for organizing the elements of the patient record over time and as an aid to navigation: the visual time bar.
Here’s how it works:
A permanent time bar (interactive timeline) at the top of the computer screen organizes all the patient’s EMR files as a function of time. The time bar remains a fixed part of the screen design, always present, regardless of what other file or files are being viewed below it. The scale of the time bar can either be linear or, as in this example, logarithmic, with more of its length allocated to the more recent history.
Each EMR file (event) for the patient is represented by an icon. In this example, there are icons for office visit, labs, ECG, and eye exam, connected to the time bar by vertical lines. Because the vertical lines accurately position each event on the time bar, the date of each event is usually omitted in order to reduce clutter.
I can open and view any individual file (event) by clicking directly on its icon. That icon will highlight (indicated in this example by a thick red border) while the file is open, providing me with unambiguous, immediate, and reflexive knowledge of how this file fits into the larger time framework. While a file is open and its icon is highlighted, its exact date will display within the time bar.
In addition to being able to display a file by clicking directly on its icon, I can also step backward or forward in sequence through the files in a patient record by clicking on the back or forward buttons (< , >).
On the right side of the screen, the icons are displayed in column form. I can easily select a subset of files (events) for viewing by clicking on one or more icons in this column.
I can focus in on a particular interval of time (such as just the past 1 month or just the 2008 calendar year) by using the selection boxes (1 mo, 3 mo, etc.) and/or by using the sliding tabs beneath the time bar. That segment of the time bar would then be ‘exploded’ to occupy most of or all of the length of the bar.
The basic time bar design idiom clearly permits multiple solutions, each with unique advantages and disadvantages. What I have presented above is one possible realization. Additional possible design options could include the following:
Rick Weinhaus, M.D.
Watertown, MA
Dr Weinhaus,
Thank you for such a fantastic post.
I only had the opportunity to do one course in Usability at University but what a fantastic class and there are not nearly enough texts on the subject.
The timeline concept is something that is certainly a very cool and I recall a few books that cover it BUT you have posted something I have never seen - applying a physicians view in detail. Worth its weight in gold to open source and commercial vendors alike.
We have only recently started apply bells and whistles to PatientOS from a usability perspective - it is the most satisfying aspect though - and while I and my team are over committed and over extended I will say that sooner than later I will have for you an implementation of this timeline and I think it will be fascinating to see you use it. What I think is most interesting is that often what appears great in design can be far more complex in reality due to the quantity of data, performance constraints, and the limitation of the User Interface (for web applications).
Something Medtuity (one of my fav commercial apps) and PatientOS have in common is a rich client interface where UI limits are only governed by the cost of writing them and so for fun I'll throw a wager on the table that PatientOS with its Java based modern architecture can deliver something close to your vision faster than Matt can do in C++. Of course I can't start this week - but I bet Matt can't either :-)
What say you Matt?
Greg
http://www.patientos.org
Greg--Principal at PatientOS Inc. (888)-NBR1-EMR
rweinhaus:As many contributors to this forum have noted, the lack of usability of EMR software remains a major obstacle to its acceptance and widespread use.
Yes, they all suck.
Just this month, The National Research Council reported that currently implemented healthcare IT programs often ‘provide little support for the cognitive tasks of the clinicians or the workflow of the people who must actually use the system.
2/2 there.
Moreover, these applications do not take advantage of human-computer interaction [HCI] principles, leading to poor designs that can increase the chance of error, add to rather than reduce work, and compound the frustrations of executing required tasks.’ (http://books.nap.edu/openbook.php?record_id=12572&page=R1 , page S-3). (NOTE: I can't find page S-3) Bingo ! I believe that there is a pressing need improve EMR software by taking advantage of what we know about how the human brain takes in, organizes, and processes information. I envision a user-centered EMR, simple, powerful, elegant, and built from the ground up on principles of interaction design. Sure, Beauty = Power / Complexity. Everyone wants that but no one has really gotten there. In this first thread, I would like to present a visual idiom for organizing the elements of the patient record over time and as an aid to navigation: the visual time bar. Sure. But keep in mind, getting the data in efficiently is often the biggest barrier. How about addressing that ! >>>> A permanent time bar (interactive timeline) at the top of the computer screen organizes all the patient’s EMR files as a function of time. The time bar remains a fixed part of the screen design, always present, regardless of what other file or files are being viewed below it. The scale of the time bar can either be linear or, as in this example, logarithmic, with more of its length allocated to the more recent history. Whoa..... nothing is permanent. Do you mean I'll see this timeline ON EVERY screen, or just on screens when I am reviewing things. I am sure there are many screens that this would just take up screen space. Logarithmic is a good idea. >>>> Each EMR file (event) for the patient is represented by an icon. In this example, there are icons for office visit, labs, ECG, and eye exam, connected to the time bar by vertical lines. Because the vertical lines accurately position each event on the time bar, Can you redo your screen for my patients on Warfarin (Coumadin) that get their blood drawn 18 times per year (at three weekish intervals) ? Please add 6 doctor visits, 2 other lab tests (useful ones) , 1 CT, 1 U/S, 8 specialist vists from 4 different specialists, 1 EKG, 1 hospital admission, 1 Bone density. The patient is on 13 Medications and 4 changed that year. >>>> the date of each event is usually omitted in order to reduce clutter. small point but true nevertheless. >>>> I can open and view any individual file (event) by clicking directly on its icon. That is a time consuming method. >>>> That icon will highlight (indicated in this example by a thick red border) while the file is open, providing me with unambiguous, immediate, and reflexive knowledge of how this file fits into the larger time framework. While a file is open and its icon is highlighted, its exact date will display within the time bar. Intuitive Method. >>>> In addition to being able to display a file by clicking directly on its icon, I can also step backward or forward in sequence through the files in a patient record by clicking on the back or forward buttons (< , >). I think that would work nice, you better have AJAX, because I am not waiting for server requests with every forward or back ! BTW, which platform is this EMR going to be written in ? >>>> On the right side of the screen, the icons are displayed in column form. I can easily select a subset of files (events) for viewing by clicking on one or more icons in this column. Can be useful, but would probably be used only rarely. In my typical day, I rarely perform this task you outline here. What exactly am I doing here ? Looking at what has been done on the patient ? Try to outline for me 3 clinical scenarios where I would need this. Be ultra specific. How badly does the paper chart fail here ? My EMR does it like this. In what scenarios would your design outperform the design above ? I'm eager to talk about how my metadata will just crush your design ! You have 4 filters, I have infinite ! Note: I can also filter with buttons too (like yours) ... [ Lab, Density, Consult, ~todo ~test ] Note: ~todo are special words for me and pertain to workflow triggers. Archive is used to filter less important items. >>> I can focus in on a particular interval of time. Useful, but again, I dont have to do this alot. I deal with clinical events like: how heavy has this patient's menses been over the last 18 months. Was she complaining of clots 18 months ago ? Did I bump up her SSRI in the last year ? Any other med changes ? When was the last time Dr. U. Terus saw her about menorrhagia ? Put *THAT* on a timeline. >>> The time bar could also be used to show future events that are already scheduled or need to be scheduled (such as a yearly diabetic eye exam). Window dressing. I'm a doctor, I know that. Being reminded there is tonnes of work to do on this diabetic is more depressing than helpful. >>> The time bar could be used to select more than one file for simultaneous display. For instance, the 2 most recent ECGs could be selected to display side by side to facilitate comparison. You should come to my office to see my multi-monitor paradise. For myself, my 3 exam rooms have 2 monitors each and my workstation has 3 monitors ! A really good EMR would be designed with the idea that monitors are cheap (none exists today, BTW). >>> The time bar could be used in conjunction with a search function, for example: Search labs and office visit for ‘HLA-B27’. Any file that met the search criteria would be flagged by a change in appearance of its icon on the time bar. - Good one ! That's like my Metadata ... You DID think of it.. Congrats. This is a great feature. Of course, Synapse is doing this today. in AJAX like speed. >>> Visual ‘bookmarks’ could be used to flag important files for future reference. useful. A very important challenge for you is to PROVE your design would in fact outperform Synapse's design (as just one example, albeit a great one). Are you sure your cute little icons are of value or just cute ? While I do love discussing the merits of individual EMR GUI items ... it can be too reductionist. You might think a timeline on every screen is great, until you actually start using your EMR. This is somewhat timely as Synapse is thinking about getting a timeline ! see here: http://www.compkarori.com/timeline/timeline2.html http://synapsedirect.com/forums/thread/3226.aspx - discussion here. BTW, I really do love a great timeline. I've tried to communicate with Graham about a Concept popup or tab called "Recent", or maybe I haven't and it's just a text file on my wiki but .... I think if you expand the data elements on timeline to include tagged clinical content, meds, consults, you might have a winner. Keep in mind, that for every data element you want ... it takes time to enter .... and doctors want to do things fast. Welcome Aboard. email: | Post Points: 35
(http://books.nap.edu/openbook.php?record_id=12572&page=R1 , page S-3). (NOTE: I can't find page S-3)
Bingo !
I believe that there is a pressing need improve EMR software by taking advantage of what we know about how the human brain takes in, organizes, and processes information.
I envision a user-centered EMR, simple, powerful, elegant, and built from the ground up on principles of interaction design.
Sure, Beauty = Power / Complexity. Everyone wants that but no one has really gotten there.
Sure. But keep in mind, getting the data in efficiently is often the biggest barrier. How about addressing that !
>>>> A permanent time bar (interactive timeline) at the top of the computer screen organizes all the patient’s EMR files as a function of time. The time bar remains a fixed part of the screen design, always present, regardless of what other file or files are being viewed below it. The scale of the time bar can either be linear or, as in this example, logarithmic, with more of its length allocated to the more recent history.
Whoa..... nothing is permanent. Do you mean I'll see this timeline ON EVERY screen, or just on screens when I am reviewing things. I am sure there are many screens that this would just take up screen space. Logarithmic is a good idea.
>>>> Each EMR file (event) for the patient is represented by an icon. In this example, there are icons for office visit, labs, ECG, and eye exam, connected to the time bar by vertical lines. Because the vertical lines accurately position each event on the time bar,
Can you redo your screen for my patients on Warfarin (Coumadin) that get their blood drawn 18 times per year (at three weekish intervals) ? Please add 6 doctor visits, 2 other lab tests (useful ones) , 1 CT, 1 U/S, 8 specialist vists from 4 different specialists, 1 EKG, 1 hospital admission, 1 Bone density. The patient is on 13 Medications and 4 changed that year.
>>>> the date of each event is usually omitted in order to reduce clutter.
small point but true nevertheless.
>>>> I can open and view any individual file (event) by clicking directly on its icon.
That is a time consuming method.
>>>> That icon will highlight (indicated in this example by a thick red border) while the file is open, providing me with unambiguous, immediate, and reflexive knowledge of how this file fits into the larger time framework. While a file is open and its icon is highlighted, its exact date will display within the time bar.
Intuitive Method.
>>>> In addition to being able to display a file by clicking directly on its icon, I can also step backward or forward in sequence through the files in a patient record by clicking on the back or forward buttons (< , >).
I think that would work nice, you better have AJAX, because I am not waiting for server requests with every forward or back !
BTW, which platform is this EMR going to be written in ?
>>>> On the right side of the screen, the icons are displayed in column form. I can easily select a subset of files (events) for viewing by clicking on one or more icons in this column.
Can be useful, but would probably be used only rarely.
In my typical day, I rarely perform this task you outline here. What exactly am I doing here ? Looking at what has been done on the patient ?
Try to outline for me 3 clinical scenarios where I would need this. Be ultra specific. How badly does the paper chart fail here ?
My EMR does it like this.
In what scenarios would your design outperform the design above ?
I'm eager to talk about how my metadata will just crush your design ! You have 4 filters, I have infinite !
Note: I can also filter with buttons too (like yours) ... [ Lab, Density, Consult, ~todo ~test ] Note: ~todo are special words for me and pertain to workflow triggers.
Archive is used to filter less important items.
>>> I can focus in on a particular interval of time.
Useful, but again, I dont have to do this alot. I deal with clinical events like: how heavy has this patient's menses been over the last 18 months. Was she complaining of clots 18 months ago ? Did I bump up her SSRI in the last year ? Any other med changes ? When was the last time Dr. U. Terus saw her about menorrhagia ?
Put *THAT* on a timeline.
>>> The time bar could also be used to show future events that are already scheduled or need to be scheduled (such as a yearly diabetic eye exam).
Window dressing. I'm a doctor, I know that. Being reminded there is tonnes of work to do on this diabetic is more depressing than helpful.
useful.
A very important challenge for you is to PROVE your design would in fact outperform Synapse's design (as just one example, albeit a great one). Are you sure your cute little icons are of value or just cute ?
While I do love discussing the merits of individual EMR GUI items ... it can be too reductionist. You might think a timeline on every screen is great, until you actually start using your EMR.
This is somewhat timely as Synapse is thinking about getting a timeline !
see here: http://www.compkarori.com/timeline/timeline2.html
http://synapsedirect.com/forums/thread/3226.aspx - discussion here.
BTW, I really do love a great timeline. I've tried to communicate with Graham about a Concept popup or tab called "Recent", or maybe I haven't and it's just a text file on my wiki but .... I think if you expand the data elements on timeline to include tagged clinical content, meds, consults, you might have a winner.
Keep in mind, that for every data element you want ... it takes time to enter .... and doctors want to do things fast.
Welcome Aboard.
email:
Synapse has finished the timelines a while back, and can place visits, diagnoses, surgeries, significant social events, vaccinations etc on the timeline. Clicking on an element on the timeline brings up some data on the event.
Graham http://www.synapsedirect.com/ Synapse - the EMR for the superior physician
Dr Murdoch do you really only see 9 lines of text per page for your list of results on your 3 monitors? It could do with a splash of color and some icons :-)
Graham for your timeline do you have to add the events manually by selecting something - how do you add a diagnosis for example?
An interesting post but rudimentary in addressing the problem with a timeline.
rweinhaus:I envision a user-centered EMR, simple, powerful, elegant, and built from the ground up on principles of interaction design
Agree.
rweinhaus:I would like to present a visual idiom for organizing the elements of the patient record over time and as an aid to navigation: the visual time bar.
Nice start, but multiple problems. This model assumes a doctor thinks like the general population, concrete relationally. This is true when it comes to turning on a computer and the operating system - this is why Windows replaced DOS but is deficient when it comes to medical information organized by a doctor who thinks abstract linearly - ie, looking for a particularlar lab result trend related to visit notes and medications (both prescription and non-prescription) Almost all current EMRs are like DOS - put in the right commands (tab or button clicks) and you get what you want. If an EMR does this poorly the doc will complain with "there are too many clicks" - and is the basic complaint of the current majority of EMRs - it is basically the doc learning all those DOS commands (only in a medical operating system)
As Doc Murdock has pointed out "what about the input:"
Your model is concerned with output mainly, output is less of a problem than input. Reading a chart is easier than writing and creating a chart. Again the same principle of concrete relational and linear abstract need apply. While your diagram looks nice most EMRs do this already with less artwork and more "plain jane" display. The real problem is input that needs to be documenting by event not exception and organizationally allowing for "one click" lookup of past (and future) multiple events. And that is where Medscribbbler is going, and already incorporates some of your suggestions!
The concrete relational and linear abstract model was one I developed in the 80's during my masters degree and refined in the 90's when I was teaching cultural anthropology. Generally, I never went on for the PHD torture and never really published this, but recently there have been a few others pick up on this and every now and then a PHD candidate calls me about this idea. The most recent was one studying and developing a solution for Canadian Native Reserve business practices and solutions for the general failure of good management (by the way she was being funded by the Tribes themselves - very positive)
Enough "horn tooting" - in addition to the design you propose - remember there are limitations imposed by hardware and skill of the programmers. An EMR is basically Microsoft Office except for doctors - just guess how much code is involved in it and the size of the "team" that developed it.
Medscribbler Getting you there sooner!
Scriptnetics
866-350-6337
caultonpos:Dr Murdoch do you really only see 9 lines of text per page for your list of results on your 3 monitors? It could do with a splash of color and some icons :-)
You can't filter on icons! The button text is user configurable.
caultonpos:Graham for your timeline do you have to add the events manually by selecting something - how do you add a diagnosis for example?
When you click on the timeline button, you get a choice of what type of event to display. These include diagnoses, surgeries, visits, social events, investigations ordered, vaccinations, and scheduled vaccinations. The latter two so that you visually compare with what the child has had vs what they are supposed to have had. You also get to choose what the x-axis is eg. days, months, years and decades.
Diagnoses etc were all entered at one stage earlier. If the diagnosis is a continuing event, it is represented by a dot on the timeline. If it is an event which has both a start date and a finish date, then it is represented by a horizontal bar on the timeline for that time period.
If the diagnosis has no time data associated eg. no age of onset, then it is displayed below the graph and indicated as missing data.
Everything is structured data except for social events. This is parsed from the social free text looking for an event preceded by a date value.
If you look at the source for the timeline, you will see that the data is embedded in JSON format ie. the timeline is dynamically created.
HTH.
The demo that Jason linked to is a flat timeline.
But if you have lots of clustered events, you can alter it so that you can zoom in on a particular time period using the mouse scroll wheel. These are called hotspots.
I think timelines are useful for getting an overview of the patient, but I wouldn't use it as a navigational tool as the first author suggests .. it just takes too much visual real estate.
gchiu: You can't filter on icons!
You can't filter on icons!
Sure I can :-)
I think my ultimate EMR would involve: A great timeline with filters, tags, and digital ink. Tags being the most important part. Sprinkle in a bit of dictation and a Medical PBX. Intranet text and voice messaging. Top it off with a patient-friendly portal with a solid Registry driving it. And you are done.
I would probably supplement it with a good paper bridge.
That feels good.
and bad at the same time.
caultonpos:Sure I can :-)
Please explain.
At the moment we use a button and the current text tells the user what the filter is.
How can an icon do that??
I was hoping that my time bar thread might generate some interest, but I never expected such detailed, thoughtful, and incisive comment, especially within the first 24 hours of posting. Greg, DrMurdoch, CEO Mike, and Graham, I look forward to addressing the very real issues that you raise. Because your posts were so detailed, I will plan to respond to each one individually in the near future.
Let me just say here two things. First, the time bar idiom and the other ideas I am planning to post are all concepts in progress. They are not final concepts or proposals for a finished EMR design. Rather, my hope was to generate discussion about their merits and to investigate with members of the emrupdate community the relative pros and cons of different design concepts. In this regard, Dr. Murdoch, am particularly interested in exploring with you the issue you raise about whether the time bar idiom has any advantages over the Synapse model. I think that it may, but clearly there are trade-offs.
Second, while I feel that the time bar is a very useful organizing principal for navigation and for forming a mental model of the patient’s health over time, I hope I did not give the impression that the time bar idiom was the solution to a usable EMR, or even its centerpiece. I see the time bar as one possible component of a well-designed EMR program and it may make more sense later in the context of other design principles I plan to present, especially the principle of spatial memory.
By the way, I chose the term time bar, as opposed to time line, because I wanted to indicate that it was an interactive tool, in the same was as a menu bar or tool bar.
I agree that data entry is at least as big a problem as retrieval. I am of that school that has real problems with the idiom of templates for data entry. In my next thread I will propose an alternative to template-driven data entry.
Thank you all for welcoming me to your community.
Well
gchiu: caultonpos:Sure I can :-) Please explain. At the moment we use a button and the current text tells the user what the filter is. How can an icon do that??
You said "You can't filter on icons!"
You could for example have a list of consults, with a small icon of an eye, ear, heart of any other icon depending on the specialist.
Clicking on the icon filters the list to only show the documents from that specialty.
Clicking on it again turns the filter off.
Not doubt there are other examples.
I should have said, you can't filter with much precision using icons
Rick
MS CUI project is all about developing innovative ways of looking at data so you might want to check out their demos. They also use time bars.
However, I've found that you need a grunty PC as the UI is quite sluggish otherwise.