emr ehr usability

Delightful Demo of Medication Reconciliation Prototype

Our colleagues at the University of Maryland Human-Computer Interaction Lab have produced a dramatically effective prototype for medication reconciliation. It is amazingly effective, and gets better with each revision (I'm aware of three versions).

What is medication reconciliation?

That's when a healthcare provider has to compare two versions of your medication list. Say you go see your physician, who gives you a printed copy of your medication list as it was the last time you visited them. Now, you compare it to your personal list (or sack of bottles) of medicine. Do they match? If not, what's missing, what's extra, or what has changed?

If you think that sounds easy, you might think otherwise if you happen to be taking a dozen different medications. It's not that far fetched if you have the big 4 (diabetes, high blood pressure, high cholesterol, and obesity), and then toss in a couple more problems (depression, arthritis, sexual disorders). It's easy to rack up 1-3 medicines per problem.

Watch this short video to see what reconciliation involves. Dr. Catherine Plaisant narrates.

What's the big deal?

When I show this to physicians and nurses who have to do this job manually every day, they are amazed and impressed, and they want it NOW in their own electronic health record software!

Here are some features that make it so effective:

  • Animation: The logic becomes transparent
  • Proximity: Like items merge, unlike items move farther apart
  • Alignment: Columns convey meaning, and condensing adds visual efficiency
  • Color: Meaningfully employed. Green is ready to go, gray is retired to the sidelines.
  • Cognitive effort reduced: Software does the matching, rearranging and condensing, then proposes "near matches" for human adjudication.
  • Highlight differences: The text that doesn't match in two items is highlighted, adding efficiency, accuracy, and safety.

Dashboards - Quality Performance at the Point of Care

I used to get quality reports once a year, then once a quarter. They were long, opaque, boring, and too detailed to digest. I was usually looking at them when I was too tired (at the end of a long day) and away from the battlefield. As a result, nothing much changed.

So, our team decided to provide "just in time" quality feedback to physicians at the point of care, and only for diabetes, and only for 8 quality indicators (there are dozens competing for my attention). The hope was that by giving feedback as the physician was about to see the patient, then she could take action and address the issues of concern. Here's what we built:

diabetes dashboard
Fig 1. Diabetes Dashboard

Here's a closer view of just the bottom of the dashboard showing the Quality Performance Indicators (back then, the Medicare Quality Program was called "PQRI"):
quality panel of Diabetes Dashboard
Fig. 2 The "quality panel" of the Diabetes Dashboard

I call the little red, gray, and white circles "idiot lights". A more socially acceptable term is "traffic lights". They alert the physician to the actionable items for the task at hand: "Change the medications or diet to lower the blood sugar, order the cholesterol tests and annual urine micro-albumin test, and send the patient to the eye doctor."

Does this approach work?
Yes and no.

It is much easier to see what needs to be done. The effort to navigate around to find these 8 items used to take 60 clicks and about 6 minutes to find all 8 measures in our EHR. With the dashboard, it takes 6 clicks and a minute or two. That's a huge gain in efficiency and reduction in cognitive load. It's also safer and more accurate, because, frankly, most physicians would stop looking for that last item or two (the foot exam and eye exam are hardest to find) before wasting the the whole 6 minutes.

Do physicians improve their quality scores by making this more available?
Not necessarily. It's not a required view, and it's on page 2. If my nurse prints it out, circles the items needing attention, and thrusts it in my face (we are a finely-tuned team), then things happen. Otherwise, the 15 other details may get in the way. Information helps, but system processes need to change to get results.


AHRQ just published a new white paper last week.
You can read it here as a PDF.

From World Usability Day 2006 poster
The objectives of the project that led to this paper were:

  • Testing and evaluating usability throughout the product life cycle.

New AHRQ-Funded Reports on Usability of EMRs

I'm excited!


