Emergency Medicine Core Content: ThyroidDiabetes

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User Interaction Design

• Keith Conover, M.D., FACEPDepartment of
  Emergency Medicine, University of Pittsburgh

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Perspectives User, Selector, Designer

• Cooper/Nielsen Epigrams
• ED staff characteristics
• Bad and good examples
• Error and computers
• Usability and User Interaction Design (User
  Interface) Principles
• Books and websites

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• The User Is Always Right
• The User Is Not Always Right

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• Users are Not Designers
• Designers are Not Users
• Vice Presidents are Not Users

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• ED Staff

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Interrupt-driven, Multi-tasking

• Chisholm CD, Collison EK, Nelson DR, Cordell
  WH. Emergency department workplace
  interruptions are emergency physicians
  "interrupt-driven" and "multitasking"? Acad
  Emerg Med 20007(11)1239-43.

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(From critical incident stress training materials)

• Emergency services workers
• have obsessive/compulsive personality traits
• like to be in control
• are risk oriented
• are action-oriented
• need to be needed
• are dedicated

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• Help Doesnt

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• Examples

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• Times out and disappears, even in middle of ED
  workroom sign in with network password and start
  FirstNet
• Right-click patient name from 16 items on
  context menu, select not Discharge Instructions
  but Patient Education
• Once discharge instructions prepared, do NOT hit
  OK, hit Print
• When prompted by dialog box, select "yes" to
  complete followup.
• Once done with followup, press "Resume Print"
• When see dialog box for "Do you want to complete
  prescriptions for PATIENT NAME press yes.
• Once done with prescriptions, press the "Sign
  Orders" button.
• Then, the discharge instructions will print
  (usually)
• Also remember to right-click the patient's
  Patient Care column and, from the full-page
  dialog box with two tabs, 31 checkboxes of two
  different types, and two pick lists, select
  "Discharge before the nurse discharges the
  patient and the name disappears and you cant do
  it any more

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Object-Oriented Programming

• Information-hiding
• Encapsulation

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Usability Testing

• The sleep-deprived intern 30-second orientation
  test

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Standing Orders

• Computer-based Standing Orders better than
  reminders for enforcing standards and preventing
  omission errorsDexter PR, Perkins SM, Maharry
  KS, Jones K, McDonald CJ. Inpatient
  computer-based standing orders vs physician
  reminders to increase influenza and pneumococcal
  vaccination rates a randomized trial. JAMA
  2004292(19)2366-71.

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Taped-On Instructions
Mullet K, Sano D.Designing Visual Interfaces
Communication Oriented TechniquesSunsoft, 1995
Like the presence of taped-on instructions in the
physical workplace, the presence of help text in
the interface is itself a reliable indicator of
flaws in the underlying design.
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A door that needs a user manual even a
one-word user manual is a design failure.
Donald Norman
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• Less is More
• No matter how cool your interface, less of it
  would be better.

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• A dialog box is another room. Have a good reason
  to go there.
• Build function controls into the window where
  they are used.

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• Error and Computers

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Error in Medicine
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100,000 Avoidable Deaths a YearHarvard Medical
Practice Study, 1984
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Institute of MedicineTo Err is Human

• Institute of Medicine
• Part of National Academy of Science
• To Err is Human Building a Safer Health System
  2000

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Computers will Change Your Future!!!!!!!!!!!!!!!
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How ED Staff View HIS Systems (courtesy Alan
Cooper)
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• Shortly after midnight, a resident of a small
  town in southern California called the police to
  report hearing a man inside a house nearby
  screaming, "I'm going to kill you! I'm going to
  kill you!" Officers arrived on the scene and
  ordered the screaming man to come out of the
  house. The man stepped outside, wearing shorts
  and a polo shirt. The officers found no victim
  inside the house. The man had been yelling at his
  computer. Based on the preliminary report of the
  Seal Beach, CA Police Dept. (June 8, 2002) and
  the police log of the Long Beach (CA)
  News-Enterprise (June 12, 2002), p. 18

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Undo is for exploration, not for mistakes Undo
reassures
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CPOE to prevent error?

• 450 million hospital HIS failure VA Hospital at
  Bay Pines, Florida
• Deinstall of CPOE at Cedars-Sinai due to
  physician revolt
• Dr. David Classen of First Consulting Group says
  gt 6 other hospitals also deinstalled HIS

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CPOE to prevent error?

• At EDIS 2005 deinstallation forum multiple
  complaints that a major HIS vendors ED module
  totally unusable.
• Rush in Chicago has CPOE everywhereexcept in the
  ED.
• Koppel R, Metlay JP, Cohen A, et al. Role of
  computerized physician order entry systems in
  facilitating medication errors. JAMA
  2005293(10)1197-203.

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Nielsen on Koppel
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• Principles

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What is usability?
Nielsen J. Usability Engineering. Academic Press,
1993
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Goal-Directed Design

• Not looking stupid
• Not making any big mistakes
• Getting an adequate amount of work done
• Having fun (or at least not being too bored)

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Goal-Directed Design
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Implementation vs.Mental Models
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Hide The Ejector Seat Levers
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Learning Curves
Effort
Results
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Learnability/ Memorability
Lindgaard G, Chessari J, Ihsen E. Australian
Telecommunications Research 21(2)17-29

• Learnability
• ISO icons interpreted correctly by 2/3 of
  subjects
• 6/12 by knowledgeable users 1/12 by new users
• Washington, D.C. Park and Ride signs
• Good Learnability
• Excellent Memorability
• Kiss and Ride signs
• Poor Learnability, but
• Excellent Memorability

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PEN-Ivory screen
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Response Time

• Feeling of direct manipulation 0.1 second
• Longer, and no feeling of control
• Waiting for computer 1 second
• Longer, and users restrict use of system
• --Nielsen, Jakob. Designing Web Usability
• Much worse in ED

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Design Integrity
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Design Integrity
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Japanese Kanban Signs
Mullet K, Sano D.Designing Visual Interfaces
Communication Oriented TechniquesSunsoft, 1995

• Shibui subdued beauty
• Wabi elegant simplicity

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Abstraction and Simplicity in Design
Mullet K, Sano D.Designing Visual Interfaces
Communication Oriented TechniquesSunsoft, 1995
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• Your Best Guess is Not Good Enough

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Tognazzinis Paradox
Tognazzini, B (Tog). TOG on Interface.1992
Reading, MA Addison-Wesley.

• 3.
• Are the words above in color? Color 0. BW
  0. Green 100.

• Problem find out if user has a color monitor
• 1. Are you using a color monitor?
• 2. Is the picture above in color? Failure 25

Green
Blue
Orange
Magenta
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Tognazzinis Paradox

• 5. Are the words above in several different
  colors? Color 0. BW 20. Green 25.
• 6. Do the words above appear in several different
  colors? 0 failure!

Green

• 4.
• Are the words above in more than one color?
  Color 0. BW 20. Green 50.

Blue
Orange
Magenta
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Changing One Word

• NEXUS cervical-spine clearing failures in EMS
  wording changed
• Signature block for standing orders

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Customizable Tracking Board?

• Users can click on any column heading to sort
  by that category, can drag the lines to make
  columns wide or narrow, or even hide them
  altogether.

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Users are Not Designers

• Leaving the design to the users is the ultimate
  abdication of the designers responsibility to
  provide a quality product, and many studies have
  shown that users customize their interface in
  ways that are detrimental to their productivity.

Jakob Nielsen, Foreword to Mullet K, Sano D.
Designing Visual Interfaces.
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Posture

• Sovereign Posture
• Takes over entire screen
• Expects to be solely in charge of the computer
  and the user
• E.g., word processor, spreadsheet
• Daemonic Posture
• Only needs a little bit of screen
• just one of many things getting attention from
  computer and user
• E.g., modem dialup applet

• Coke Machine kiosk drive-through
  posture
• Takes over entire screen
• Expects to be solely in charge
• Always the same whenever anyone walks up to it
• Interface is extremely simple, learnable,
  memorable

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• Imagine users as very intelligent but very
  busy.

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Educational Objectives

• Cognitive Whorf-Sapir Hypothesis
• Psychomotor
• Affective

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• Browsing for All

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• Books for All

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Stalins StatueNext Slide, Please!
An integrated application solution for show
trials!

• For re-education campaigns, nothing is better
  than the Autocontent Wizard!

Theres no bullet list like Stalins bullet list!
Comrade, why are we having this meeting? The
rate of information transfer is asymptotically
approaching zero!
But why read aloud EVERY slide?
Military Parade, Stalin Square, Budapest, April
4, 1956
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• Books for Vendors and Developers

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• If Your Mind Isnt Full Already . . .
  Questions?