Nielsen's Usability Heuristics Applied to Electronic Health Records

Digital Medical Record
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A heuristic is a rule of thumb or mental shortcut that allows people to quickly make decisions and solve problems. There are several sets of heuristics applicable to designing and evaluating the user interface of electronic health records (EHRs). This article will review Jakob Nielsen’s “10 Usability Heuristics for User Interface Design” and give examples of how the heuristics can be observed or violated in an EHR.

1. Visibility of system status

“The system should always keep users informed about what is going on, through appropriate feedback within reasonable time.”

Heuristic observed: When EHR transmits computerized physician order entry (CPOE) -- to send an electronic prescription to a pharmacy, for example -- the EHR displays the status of the order transmission. The EHR alerts the user if the transmission has failed.

Heuristic violated: The EHR does does not display the order status, so that the user cannot determine if the order was sent successfully or not.

2. Match between system and the real world

“The system should speak the users' language, with words, phrases and concepts familiar to the user, rather than system-oriented terms. Follow real-world conventions, making information appear in a natural and logical order.”

Heuristic observed: Medication prescription elements in customary order of elements, e.g. “Lisinopril 20 mg once daily by mouth.”

Heuristic violated: Prescription elements are out of order.

Heuristic observed: Template-driven elements of the progress note (e.g. review of systems, physical exam) are displayed in the sequence and language familiar to clinicians.

Heuristic violated: Elements out of order.

3. User control and freedom

“Users often choose system functions by mistake and will need a clearly marked "emergency exit" to leave the unwanted state without having to go through an extended dialogue. Support undo and redo.”

Heuristic observed: The EHR allows the user to edit, review, save, and cancel unsaved changes to CPOE and clinical notes before they are finalized.

Heuristic violated: The EHR does not allow the user to make changes before CPOE and clinical notes are finalized.

4. Consistency and standards

“Users should not have to wonder whether different words, situations, or actions mean the same thing. Follow platform conventions.”

Heuristic observed: The EHR presents only one option for executing a specific CPOE (although the user may be able to access the option from multiple pathways).

Heuristic violated: The EHR offer options to “re-order” and “renew” medications without explaining the difference (if there is any difference) between the two.

Heuristic observed: The EHR clearly indicates how different pathways to selecting a medical problem from a menu (e.g. hypertension) will place the problem on the sections for past medical history, active problems, current diagnoses, or billing diagnoses.

Heuristic violated: The EHR does not clearly display how the different ways of selecting a medical problem will place the problem in various sections.

5. Error prevention

“Even better than good error messages is a careful design which prevents a problem from occurring in the first place. Either eliminate error-prone conditions or check for them and present users with a confirmation option before they commit to the action.”

Heuristic observed: The EHR checks for drug-drug interactions and displays relevant alerts early in the ordering process.

Heuristic violated: The EHR displays alerts for drug-drug interactions late in the process, which makes it likely that the clinician will override them (Hayward 2013).

Heuristic observed: The EHR does not allow the user to select electronic prescriptions for medications for which pharmacies do not accept electronic prescriptions (e.g. controlled substances).

Heuristic violated: The EHR allows the user to select electronic transmission of prescriptions for controlled substances.

6. Recognition rather than recall

“Minimize the user's memory load by making objects, actions, and options visible. The user should not have to remember information from one part of the dialogue to another. Instructions for use of the system should be visible or easily retrievable whenever appropriate.”

Heuristic observed: The EHR displays test results alongside the window for writing a message to the patient about the test results.

Heuristic violated: The EHR prevents the user from viewing test results when composing messages to the patient.

7. Flexibility and efficiency of use

“Accelerators -- unseen by the novice user -- may often speed up the interaction for the expert user such that the system can cater to both inexperienced and experienced users. Allow users to tailor frequent actions.”

Heuristic observed: The EHR user can create and customize a “favorites” list of common orders.

Heuristic violated: No favorites list.

8. Aesthetic and minimalist design

“Dialogues should not contain information which is irrelevant or rarely needed. Every extra unit of information in a dialogue competes with the relevant units of information and diminishes their relative visibility.”

Heuristic observed: The EHR limits the ability to copy-paste in progress notes.

Heuristic violated: The EHR allows excessive copy-paste, and the progress notes become bloated with extraneous, outdated information.

9. Help users recognize, diagnose, and recover from errors

“Error messages should be expressed in plain language (no codes), precisely indicate the problem, and constructively suggest a solution.”

Heuristic observed: If a clinician enters information in the wrong format, the EHR alert indicates which format should be used.

Heuristic violated: The EHR displays a generic error message without telling the clinician how to correct the error.

10. Help and documentation

“Even though it is better if the system can be used without documentation, it may be necessary to provide help and documentation. Any such information should be easy to search, focused on the user's task, list concrete steps to be carried out, and not be too large.”

Heuristic observed: The EHR displays task-specific tips when the user hovers over icons.

Heuristic violated: Documentation is inconvenient to access in the active workspace in the EHR.

Sources

Armijo D, McDonnell C, Werner K. Electronic Health Record Usability: Evaluation and Use Case Framework. AHRQ Publication No. 09(10)-0091-1-EF. Rockville, MD: Agency for Healthcare Research and Quality. October 2009. Accessed 

Hayward J et al. ‘Too much, too late’: mixed methods multi-channel video recording study of computerized decision support systems and GP prescribing. J Am Med Inform Assoc 2013;0:1–9. doi:10.1136/amiajnl-2012-001484.

Nielsen J. 10 Usability Heuristics for User Interface Design. Accessed on August 16, 2014.

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