• 5 Questions

Jon:
Welcome to Five Questions. Today my guest is Dr. Jeff Belden who is a family physician with a keen interest in the visual display of information and in EHR usability. He blogs on these topics at toomanyclicks.com. Dr. Belden is an associate professor at the University of Missouri and is the lead author of “Inspired EHRs: Designing for Clinicians†which is a generously illustrated, interactive e-book for health care app software vendors and others interested in improving the usability of EHRs. Dr. Belden welcome to the show.


Jeff:
Hi Jon, thanks. Glad to be here.


Jon:
Tell me why do you think the world needs another design pattern book? What made you take on this project?


Jeff:
I’m real sympathetic with physicians and nurses that are trying to use the current software and all of its challenges, it’s exhausting often and confusing sometimes. I can see ways to improve it from the work that we’ve done before both with collaborating with our vendor to see some improvement in their products as well as working with usability researcher colleagues. In the marketplace right now the tools that are there are a technical and divorced from the current EHR marketplace; it’s showing really old applications. What we’re interested in doing was getting closer to the middle.


Jon:
How did this project happen and who did you get to participant in it?


Jeff:
I had this idea of designing an interactive really generously illustrated e-book when Apple released iBooks Author and it made me think, you know that tool set is not that hard to use. I think I could do this on my own maybe, but it was way better to have a skilled team. I started putting the idea together, approached the California Health Care Foundation and they were interested but they wanted a funding partner so we then connected with the Office of the National Co-coordinator through the Sharp-C Project on EHR usability. The two organizations together co-funded the effort.


Jon:
You had a lot of participants from EHR vendors as well. Tell me how you went about involving the people who produce electronic health records.


Jeff:
That’s right. Through some of my volunteer work with HIMSS, which is the Health Information Management Systems Society, that’s like the world wide EHR geeks, through that organization I had gotten to know some people that work for the electronic health record vendors. They have a group called the Clinician Experience Work Group that has a special focus on user experience and so they’re the choir that we can talk to, the sympathetic ears.

They were great. They helped us coordinate with the larger organization of EHR vendors. They helped us recruit onsite workshop participants. We had workshops in Boston a couple of them and one at the University of Missouri where we had our core team plus at least a few vendor representatives where we together brainstormed ideas, figured out what was going to be most helpful to the target audience, the HR vendors and then in-between session we spent our weeks putting stuff together.

Jon:
From this group of knowledgeable people about electronic health records you’ve got all these initial ideas, how did you cull through those and come to the patterns that you ended up designing and prototyping? How did you decide what was the most important thing to focus on? The Digital Life is a show aimed at the design audience and so I know that a lot of our audience will be interested in what you found most important for these design patterns and then why you chose those.


Jeff:
I’d done a little work shopping with it in doing presentations of the general theme of medication list usability design to the same kind of audience, the HIMSS audience. I knew from those experiences the things that the audience was going to be receptive to. As a physician working with the software and talking to colleagues who are working with different brands I had a pretty strong sense of what things were missing. The usability literature also points in the direction of things that are missing.

I had empathy for the users, we had played with a lot of little sketch prototypes. I got a lot of sketch books of bad ideas, of ways to display timelines, and so we gradually boiled down to things that were more workable. We focused especially on timelines and making interactive data tables more responsive to the user needs. How can we make them sortable, filterable to help the user answer the questions that they’re trying to solve in real-time at the point of care.

Jon:
What are some of the prototypes that you built? I heard the medication list and the timeline were two of those, were there any others?


Jeff:
No. As far as prototypes go those were … Actually one other one we had twin lists which was a prototype previously developed at the University of Maryland with previous federal funding. It’s a prototype that is a really elegant way to reconcile two different medication lists. Think of this as, my medicine list that I had at home and the medicine list I’m going to go home from the hospital with after my medicines have been changed a lot. So that tool helps to provide an elegant solution to how do you compare two challenging complicated lists.


Jon:
What I thought was really interesting about this design project, besides the fact that it’s focusing on the EHRs, is that you chose to make it available open source. What was the thinking behind that decision and the decision to go with the Apache 2 open source license?


Jeff:
A couple of factors; one is we want this stuff to get out into the world and we don’t want to hold it behind some kind of pay wall where people can’t readily use it. We want vendors to take it, apply it in their products, or adopt it to their products or be inspired by it. The other thing is, of course, that these two funding agencies, California and the Feds, both are foundations that require that their products be freely available, so it was a pretty good match all the way around.


Jon:
I just want to follow up a little on this open source design for health idea because it seems to be an idea that’s picking up steam. Do you think that this model of open source design patterns is ones that other will pick up whether they’re an EHR vendor, do you imagine that they’ll contribute back to the project or do you see this as being reference material and then stopping there just being a reference or do you see this as part of a larger movement?


Jeff:
I get tired enough just thinking about finishing my own medical records, and so for me making it a reference available delights me and leaves me satisfied. I’d be very supportive of anyone’s efforts to expand the audience of participants and have the open source community participate freely and making it better. I just won’t be the guy that’ll be pulling the wagon.


Jon:
I guess that leads me to my last question today for you is; what do you see as next either for this project or … I know you had some ideas for other health IT books that might follow along the lines of Inspired EHRs, what do you see coming in the future?


Jeff:
I have maybe another dozen chapter ideas in my head. I would really like to go ahead and get started on another book or chapter. I think displaying lab results, or displaying vital signs, or some combination of those would be a nice topic. Wired Magazine did a makeover a couple of years ago where they took somebody’s cholesterol and prostrate lab results and told the design community, “Hey try to do a better job. “ That model actually has been adopted by the EHR I use in the personal health records. As a patient I go in and look at my cholesterols and it looks like the way they display it in the Wired Magazine prototype.


That didn’t really display that data over time. If I’m working with a patient to help them understand their blood pressure control, or their diabetes controls, then seeing graphical trends over time are an important part of, see when we did this, here were the results.


Jon:
In terms of these additional chapters do you see another book forthcoming or do you think you’ll release them piece meal as part of this Inspired EHRs e-book that you have available?


Jeff:
I think we’ll have to figure that out as we go. One approach would be to try do more like an e-book or and e-pub and make it a single package and then just release one after another and link back to the human factors and design reference chapters that we have in our current e-book online or we could just expand what we have. One of the things I’d like to see happen is for this whole thing to become sustainable on its own. I’m pretty sure that the foundations aren’t going to want to pay for chapter after chapter after chapter. They’re going to want to move on to new projects so I’d like to see that this has a commercial life of its own where we can put together the team, produce the work and pay for itself.


Jon:
That’s terrific. I wish you best of luck with that part of the project. Do you want to give a plug for where readers can find Inspired EHRs?


Jeff:
Yup. You can go to InspiredEHRs.org, or if you can’t remember that you can go to toomanyclicks.com and I have a link there in one of the recent posts.


Jon:
That brings us to the end of our questions for this segment. Dr. Belden thanks for joining us today and we’ll look forward to seeing Inspired EHRs hopefully grow in the future.


Jeff:
I hope so. Thanks for having me Jon.


Jon:
Sure, all right.