Challenges to Studying Usability in Clinics and Hospitals
Usability work with EMRs is not straightforward. Usability professionals, in our experience, face significant challenges in clinical environments when tasked with making an EMR more usable. Clinicians use foreign terminology; clinicians have very broad and deep knowledge; physicians have enormous power (political as well as life-and-death) in clinical settings; and privacy as well as limited access to busy physicians can keep usability professionals from observing physicians at work.
One challenge to understanding users and their tasks is the depth and breadth of user knowledge. All physicians have broad knowledge of human health, medications, and medical procedures. Typically, though, each physician also has deep knowledge in a specialty area, such as internal medicine, pediatrics, OB/GYN, family medicine, ENT, oncology, radiology, and pharmacology. You can imagine observing three different specialists before lunch where each one discusses a different organ system, orders different tests, and prescribes different medications. To make life more challenging, different specialists also tend to use different aspects of the EMR in their work.
A usability colleague of mine once said, "Ignore the differences between users. Focus on what most users do most of the time." Unfortunately, this recommendation will probably not work in the world of medicine, where a few physicians wield enormous power over the operation of the clinic. Also, physicians in different specialties need specialized user interfaces to be productive.
Medical systems use a myriad of codes to describe the diagnoses made by the physician and the procedures that physicians order. If someone has diabetes, there is not just one code to describe it but dozens. For example, the ICD-9 category for diabetes mellitus is 250, but 250.62 is the specific code for type II diabetes mellitus with neurological manifestations. And those last two digits, .62, are required to describe an adult with diabetes on insulin who has nerve damage. Similarly, there are hundreds of codes for the procedures that a physician can order. Measure blood oxygen level is 94761, while a TB intradermal test is 86580.
Beyond codes are the hundreds of commonly prescribed medications. Some of the most commonly prescribed medications are Lipitor (cholesterol), Prevacid (acid reflux), Atenolol (beta blocker for high blood pressure), Prozac (antidepressant), and Zoloft (antidepressant). Then there are pain relievers, tranquilizers, allergy medicines, antibiotics, medicines for blood pressure, sleeping pills, and stomach remedies. Each comes in different dosages taken with different frequencies at different times of the day. And they often interact with each other and with peoples' allergies. The complexity of drugs is truly bewildering.
Beyond the lingo of medicine are the settings in which medicine is practiced. Most of us have been in an exam room at a clinic. How many of us have been in an exam room with a physician and a complete stranger? Almost none of us. Patients often want privacy, and there are privacy regulations that limit access to personal medical information. Also, physicians are very busy and sometimes reluctant to be observed while practicing medicine.