Debunking health IT usability myths.

Poor usability is a threat to patient safety and linked to productivity loss, workflow disruption, user frustration, sub-optimal product use and system de-installations. Although usability is receiving more attention nationally and internationally, myths about usability persist. This editorial debunks five common myths about usability (1) usability only concerns the look and feel of a product and is, therefore, only a minor concern, (2) usability is not measurable, (3) usability stifles innovation, (4) vendors are solely responsible for product usability, and (5) usability methods are not practical for use in healthcare.

Usability Evaluation of An Electronic Medication Administration Record (eMAR) Application.

BACKGROUND: Electronic medication administration records (eMARs) have been widely used in recent years. However, formal usability evaluations are not yet available for these vendor applications, especially from the perspective of nurses, the largest group of eMAR users. OBJECTIVE: To conduct a formal usability evaluation of an implemented eMAR. METHODS: Four evaluators examined a commercial vendor eMAR using heuristic evaluation techniques. The evaluators defined seven tasks typical of eMAR use and independently evaluated the application. Consensus techniques were used to obtain 100% agreement of identified usability problems and severity ratings. Findings were reviewed with 5 clinical staff nurses and the Director of Clinical Informatics who verified findings with a small group of clinical nurses. RESULTS: Evaluators found 60 usability problems categorized into 233 heuristic violations. Match, Error, and Visibility heuristics were the most frequently violated. Administer Medication and Order and Modify Medications tasks had the highest number of heuristic violations and usability problems rated as major or catastrophic. CONCLUSION: The high number of usability problems could impact the effectiveness, efficiency and satisfaction of nurses' medication administration activities and may include concerns about patient safety. Usability is a joint responsibility between sites and vendors. We offer a call to action for usability evaluations at all sites and eMAR application redesign as necessary to improve the user experience and promote patient safety.

Informatics competencies for nurses at four levels of practice.

Valid and comprehensive nursing informatics (NI) competencies currently are lacking. Meanwhile, nursing leaders are emphasizing the need to include NI in nursing curricula, as well as within the roles of practicing nurses in all settings. This article presents the initial work of a team of NI experts toward development of a valid and reliable set of NI competencies. Previous work primarily has focused on computer-related skills, rather than examining a broad definition of informatics competencies. For this current work, NI competencies encompass all skills, not only computer-related skills, as well as knowledge and attitudes needed by nurses. The first two authors created a database of NI competencies from the existing literature. A larger panel of NI experts then affirmed, modified, added, or deleted competencies from this database. Competencies were placed into four distinct skill levels. Definitions of each skill level and an initial master list of competencies are provided.

History and trends in clinical information systems in the United States.

PURPOSE: To provide a synopsis of issues about clinical information systems for nurses not schooled in nursing informatics. ORGANIZING CONSTRUCT: The past, present, and future of clinical computing, including major factors resulting in the early hospital information systems (HIS) and decision support systems (DSS) in the United States, current advances and issues in managing clinical information, and future trends and issues. METHODS: Literature review and analysis. FINDINGS AND CONCLUSIONS: The first HIS and DSS were used in the late 1960s and were focused on applications for acute care. The change from fee-for-service to managed care required a change in the design of clinical information systems toward more patient-centered systems that span the care continuum, such as the computer-based patient record (CPR). Current difficulties with CPR systems include lack of systems integration, data standardization, and implementation. Increased advances in information and technology integration and increased use of the Internet for health information will shape the future of clinical information systems.

Using a web-based prototype and human-computer interaction concepts to develop a vision for a next generation patient care management system.

This paper describes the novel use of two tools to develop requirements for a new generation patient care system: a web-based prototype and a human-computer interaction framework. These tools allowed a development team to crystallize new requirements for a patient care system, illustrate to clinicians a radical change in care process models, and begin the change management process in a large enterprise.

Health professionals' views of informatics education: findings from the AMIA 1999 spring conference.

Health care leaders emphasize the need to include information technology and informatics concepts in formal education programs, yet integration of informatics into health educational programs has progressed slowly. The AMIA 1999 Spring Congress was held to address informatics educational issues across health professions, including the educational needs in the various health professions, goals for health informatics education, and implementation strategies to achieve these goals. This paper presents the results from AMIA work groups focused on informatics education for non-informatics health professionals. In the categories of informatics needs, goals, and strategies, conference attendees suggested elements in these areas: educational responsibilities for faculty and students, organizational responsibilities, core computer skills and informatics knowledge, how to learn informatics skills, and resources required to implement educational strategies.

The vision for the Department of Defense's computer-based patient record.

To meet the Department of Defense's clinical information management mission for the next century, a vision for the computer-based patient record (CPR) was needed. This article describes the generation of that vision as well as the resulting definition, characteristics, and essential functions of the Department's CPR.

Comparing response time, errors, and satisfaction between text-based and graphical user interfaces during nursing order tasks.

Despite the general adoption of graphical users interfaces (GUIs) in health care, few empirical data document the impact of this move on system users. This study compares two distinctly different user interfaces, a legacy text-based interface and a prototype graphical interface, for differences in nurses' response time (RT), errors, and satisfaction when the interfaces are used in the performance of computerized nursing order tasks. In a medical center on the East Coast of the United States, 98 randomly selected male and female nurses completed 40 tasks using each interface. Nurses completed four different types of order tasks (create, activate, modify, and discontinue). Using a repeated-measures and Latin square design, the study was counterbalanced for tasks, interface types, and blocks of trials. Overall, nurses had significantly faster response times (P < 0.0001) and fewer errors (P < 0.0001) using the prototype GUI than the text-based interface. The GUI was also rated significantly higher for satisfaction than the text system, and the GUI was faster to leam (P < 0.0001). Therefore, the results indicated that the use of a prototype GUI for nursing orders significantly enhances user performance and satisfaction. Consideration should be given to redesigning older user interfaces to create more modern ones by using human factors principles and input from user-centered focus groups. Future work should examine prospective nursing interfaces for highly complex interactions in computer-based patient records, detail the severity of errors made on line, and explore designs to optimize interactions in life-critical systems.

An operational model for patient-centered informatics.

There are no multidisciplinary operational models to guide nursing informaticists and clinical system users in the design and implementation of computer-supported multidisciplinary care. The Patient-Centered Informatics Model is offered as just such a pragmatic guide. It fuses earlier work with new concepts and allows a visual depiction of crucial elements-influencing factors such as regulations and healthcare delivery models, system attributes such as healthcare delivery methods, knowledge base and supporting technology and categories of results of application processing. The model can help users and executives organize their thinking about the design, implementation, and evaluation of clinical systems in complex settings.

Analysis, processes, and techniques. Case study.

The case studies will represent a wide variety of scenarios encountered in the field of healthcare information system technology implementation. We hope that the series will be of value to readers of Computers in Nursing. We encourage feedback so that subsequent cases within the series can be tailored to meet the needs of readers.

A provocative look at performance measurement.

A fascinating web of issues can be spun from the notion of performance measurement. After a brief discussion about the background of performance measurement, this article puts performance measurement into a fresh light by examining three major issues: the concept of quality and its application to performance measurement, the power of the patient and the transition of focus to customers within health care organizations, and deliberations about data and concomitant implications for information systems of the future.

A classification scheme for outcome indicators.

PURPOSE: To provide a framework for classifying outcome indicators for a more comprehensive view of outcomes and quality. METHODS: Review of outcomes literature published since 1974 from medicine, nursing, and health services research to identify indicators. Outcome indicators were clustered inductively. FINDINGS: Three groups of outcome indicators were identified: patient-focused, provider-focused, and organization-focused. Although investigators tend to focus on a select few outcome indicators, such as patient satisfaction, quality of life, and mortality, many indicators exist to measure outcomes. CONCLUSIONS: Selecting and integrating a wide array of outcome indicators from the various categories will provide a more balanced view of health care delivery as compared with focusing on a few common indicators or only one category.

The language of outcomes.

Outcomes are a topic of great interest. Their potential is considerable as a mechanism to evaluate quality, improve effectiveness, and link practice to professional accountability. Greater clarity and precision in the use of outcomes terminology will allow this potential to be realized. This article identifies the current confusion in outcomes terminology, begins an outcomes lexicon, and issues a call to action for further clarification in the language of outcomes.

Notes from a clinical information system program manager. A solid vision makes all the difference.

Today's CIS manager will create a vision that connects computerization in ambulatory, home and community-based care with increased responsibility for patients to assume self-care. Patients will be faced with a glut of information and they will need nursing help in determining the validity of information. The new vision in this environment will focus on integration, interoperability, and a new definition for patient-centered information. Creating a well-articulated vision is the first skill in the repertoire of a CIS manager's tool set. A vision provides the firm structure upon which the entire project can be built, and provides for links to life-cycle planning. This first step in project planning begins to bring order to the chaos of dynamic demands in clinical computing.

Strategies for successful clinical information system selection.

The CIS market is volatile. With consumer pressure to develop and the current interest in CISs, clinicians recommended reassessing the market again in 18 months. Even without fully mature systems, there are foundational CISs available on the market. Strategies for successful CIS selections are many: Decide to be a developer or buyer early in the process. Entering into a long-term relationship with a vendor to develop customized capabilities will mandate different requirements than purchasing a ready-to-use system. Use a systematic method for evaluating systems, preferably multimethod. Force structure into the evaluation process with vendors, especially for the system demonstration. Structure will ensure that each system function, or lack of function, is exposed and assessed and will allow for consistent and fair evaluations across vendors. Make the vendor commit to distinguishing between existing and proposed functions during system demonstrations. Often, vendors promise the very functions you want to be in the next release. Most vendors will cooperate with structured schedules. However, some vendors may resist structure because it interferes with marketing strategies. If, despite requests for specific materials and schedules, vendors fill the time with unsolicited material, ask yourself why and beware: they may not have the functions you requested. Use a brief clinical scenario as a preview into system functions, integration, and system usability. Ask vendors for conceptual models of system functional and technical architecture. Use an interdisciplinary team. Focus subgroups in specialty areas for efficiency and effectiveness in evaluation. Consider tape-recording the joint group sessions for later confirmation or analysis. Consider application integration as one of the major requirements for future CISs, especially between ambulatory and inpatient arenas.