Human-computer Interaction in Healthcare: A National Priority

Titus Schleyer, DMD, PhD
Carnegie Mellon University, HumanComputer Interaction Institute

September 14, 2011
Denia, Spain © Titus Schleyer 2011

Center for Dental Informatics University of Pittsburgh School of Dental Medicine

Today’s talk
• • • • • • a fundamental question for usability the federal case for usability in healthcare the health care process and health records a brief tour of an electronic dental record sample projects in user-centered design getting you involved

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Can poor usability kill?
Medical Devices: The Therac-25
Nancy Leveson University of Washington

1

Introduction

Between June 1985 and January 1987, a computer-controlled radiation therapy machine, called the Therac-25, massively overdosed six people. These accidents have been described as the worst in the 35-year history of medical accelerators [6].

Can poor usability kill?

Can poor usability kill?
4 Casual Factors
• Overconfidence in Software. … • Lack of Defensive Design. …

• Inadequate Software Engineering Practices. …
• Save versus Friendly User Interfaces. …

Leveson NG. Medical devices: the Therac-25. In: Safeware: system safety and computers. Boston: Addison-Wesley; 1995. p.515-53.

The situation today …
• “Some unintended consequences of information technology in health care: the nature of patient care information system-related errors” • “Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system” • “Identifying and quantifying medication errors: Evaluation of rapidly discontinued medication orders submitted to a computerized physician order entry system” • “Assessment of the usefulness to use a software supervising continuous infusion rates of drugs administered with pumps in ICU and estimation of the frequency of rate of administration errors” • and 10s of other papers
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The federal case for usability in healthcare

Oxford, MD © T. Schleyer 2011

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Tasks and workflow of healthcare
• healthcare decisions that require reasoning in the face of uncertainty • complex non-transparent workflow • increasing complexity of the care provided to patients in a time-pressured environment

Stead WW, Lin HS and editors. Computational technology for effective health care: immediate steps and strategic directions, Washington, DC:National Academies Press, 2009.

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Principles of change (of 9)
• Principle 4: Design for human and organization factors • Principle 5: Support the cognitive functions of all caregivers, including health professionals, patients, and their families • Principle 8: Seek and develop technologies that identify and eliminate ineffective work processes
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Health care process and health records

Paradise, Michigan © T. Schleyer 2011

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Dental care process
Emergency patient

Assessment and diagnosis
Regular patient

Treatment plan

Health status maintenance

Treatment

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Clinical documentation
• medical and dental history, incl. chief complaint • extraoral and intraoral exam • radiographs • images • problem list • treatment plan • progress notes
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Medical history

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Medication history

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Hard tissue exam and radiology report

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Periodontal exam

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Radiographs

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Images

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Treatment plan

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Progress notes

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A brief tour of an electronic dental record: EagleSoft

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Clinical Welcome Screen

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Patient Select

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Clinical Exam

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Clinical Exam: Perio

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Clinical Exam: Head

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Charting Interface

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Chart with Alert

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Chart: Entering Findings

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Clinical Notes

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Perio Exam

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Perio Comparison: Numeric

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Perio Comparison: Graphic

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Medical History

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Imaging: Patient Photo

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Imaging: Bitewings

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Imaging: Eagle Eye

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Electronic records: Medicine

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User-centered design in healthcare: Sample projects
Thanks to:

T. Thyvalikakath
Kochi, India © T. Thyvalikakath 2011

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Project 1: Usability of four dental computer-based patient records
Research questions:
• Which usability problems are common in dental software? • What is the rate of completed, incorrectly completed and incomplete user tasks?

Thyvalikakath T et al. A usability evaluation of four commercial dental computer-based patient record systems. J Am Dent Assoc 2008 Dec;139(12):1632-42

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Results

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User adverse events
70 60 50 40 30 20 10 0
ES PW DX SD

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Record a missing tooth – correct path

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User paths

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Usability of electronic dental records
• Significant usability problems due to:
– complex information design – mismatch between system and user model – difficulty in finding functionality

• significant cognitive effort required that did not contribute to task completion

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Project 2: Cognitive task analysis of dental examinations
• What cognitive processes do dentists engage in and what information do they use when they examine a patient and develop a treatment plan? • Methods
– think-aloud method with 3 standardized patient cases – 5 dental faculty and 5 general dentists – analyze the sessions to determine:
• information that dentists requested • sequence in which they reviewed information • instances of concurrent review of information items

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Results
Average of patient data accessed in 10 high complexity cases
35 Average number of times each patient data accessed 30

25

20

15

10

5

0 0% Start of 10% 20% 100% Average session time in percentage (normalized) for a case of high complexityEnd of session
Social History Medical Consult Radiographs Oral Pathology Consult Medical History Dental History Hard Tissue Chart Treatment Plan Notes

30%

40%

50%

60%

70%

80%

90%

Patient Demographics Medications Intra-oral Images Periodontal Exam

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Results (cont.)
Average of patient data accessed in 10 low complexity cases
20 Average number of times each patient data accessed 18 16 14 12 10 8 6 4 2 0 0% Start 10% 20% 100% End of Average session time in percentage (normalized) for a case of low complexity sessio
Medical History Radiographs Treatment Plan Notes Dental History Hard Tissue Chart Extra-oral Images Periodontal Exam

30%

40%

50%

60%

70%

80%

90%

Patient Demographics Intra-oral Images Financial Informaton

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Visualization of information artifacts used over time

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Project 3: Cross-platform, modular UI design
• Microsoft Common User Interface (MSCUI – www.mscui.net) • sample problem: pt. identifiers

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MSCUI: Designing for safety

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Sample design: Patient banner

(includes 26-page Design Guidance document)

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Project 4: The DMD Project

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A novel approach to designing EDRs

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Results

scale: 0 (least satisfaction) - 9 (most satisfaction)

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Results

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How do we meet these challenges?

licensed image © 123rf.com 2011

By getting you involved!
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How can you get involved?
• join the Dental Informatics Online Community (www.dentalinformatics.org) • participate in dental informatics research • get an advanced degree in dental informatics (MS, PhD, postdoc – free for qualified applicants)

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Thank You for Your Attention!
Questions, comments?
Thanks to:

T. Thyvalikakath

Please visit us at: http://di.dental.pitt.edu Twitter Facebook /titusschleyer Scribd
H. Spallek

}

H. Torres-Urquidy

P. Hernandez

J. Irwin

A. Acharya

… and many others.
© CDI 2011 Center for Dental Informatics University of Pittsburgh School of Dental Medicine

M. Song

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This talk: http://scr.bi/nWfGai

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References
1. Leveson NG. Medical devices: the Therac-25. In: Safeware: system safety and computers. Boston: Addison-Wesley; 1995. p.515-53. 2. Ash JS, et al. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004;11(2):104-12. 3. Han YY, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116(6):1506-12. 4. Koppel R, et al. Identifying and quantifying medication errors: evaluation of rapidly discontinued medication orders submitted to a computerized physician order entry system. J Am Med Inform Assoc. 2008;15(4):461-5. 5. Cayot-Constantin S, et al. [Assessment of the usefulness to use a software supervising continuous infusion rates of drugs administered with pumps in ICU and estimation of the frequency of rate of administration errors]. Ann Fr Anesth Reanim. 2010;29(3):204-8. French.
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References (cont.)
6. Stead WW, Lin HS, editors. Computational technology for effective health care: immediate steps and strategic directions, Washington, DC: National Academies Press; 2009. 7. Thyvalikakath TP, et al. Heuristic evaluation of clinical functions in four practice management systems: a pilot study. J Am Dent Assoc. 2007;138(2):209-18 8. Thyvalikakath TP, et al. A usability evaluation of four commercial dental computer-based patient record systems. J Am Dent Assoc. 2008;139(12):1632-42.

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