Enhancing the Usability of EMR through Multimodal Interactions : Vijayrajan A, CTO & CIO, Manipal Hospital, Bangalore

Electronic Medical Record

[This article was published in the January 2008 issue of the eHEALTH Magazine (]

�EMR applications and implementations need to meet the tough demands of care delivery process and environment� -Vijayrajan A, CTO & CIO, Manipal Hospital, Bangalore shares his thoughts on this critical issue that often becomes a determinant between success or failure of IT implementation in hospitals

Significant changes in Information Technology (IT) have occurred over the past two decades. This, with the availability of high-performance hardware at lower costs, is having a profound impact on the ways we conduct our business and live our lives.


“Studies show that hospitals spend only 3 percent of their revenue on IT compared to other information intensive industries where IT spending is many times higher”

Businesses that could overcome the difficulties associated with technology adoption have seen improvements in profit, through productivity gains and lower cost of operations relative to their peers, and increased market share.

By some estimates, more than 75 percent of the world’s population now lives within range of a mobile network. Technology advancements like these have created knowledge societies where knowledge forms a major component of any human activity. Social, cultural, economic and all other human activities become dependent on a large volume of knowledge and information. This also created a new class of workforce called Knowledge Workers.

Though healthcare quickly embraces new technology related to diagnosis and treatment, it has been very slow to adopt IT advancements in the care delivery process. In fact the Medical / Clinical Science involved in diagnostic devices and drug discovery have advanced more rapidly than the ability to deliver them effectively and efficiently. One of the key challenges, as always mentioned, is the ability of the care providers’ acceptance and adoption. Care Providers, who are also part of the knowledge society, in turn cite difficulties in usability as the main concern; they feel it reduces their productivity.


Electronic Medical Record (EMR)  Definition

Conventional enterprise automation Human Resources, Finance, Procurement, Manufacturing, Customer Relationship Management, etc. is handled by ERP application suites. On similar lines, the care delivery process automation including clinical data management can be realized by EMR solutions.

EMR is more than Electronic patient record. It is a Healthcare IT system. The EMR system provides support for all of the activities and processes involved in the delivery of care. It focuses on tasks and events directly related to care and it is optimized for use by clinicians.

  • Care Provider’s view of patient’s health history
  • Accessible anywhere anytime
  • Sharable among care providers
  • Document of services used for billing purposes
  • Legal document for the services rendered
  • Source for clinical Audit
  • Source for clinical research

As per the Gartner Research the core capabilities of EMR include:

  • A clinical data repository a permanent data store for the clinical information
  • Interoperability has the capability to interface with other systems
  • Support for privacy guarantees security while providing legitimate access
  • A controlled medical vocabulary to support exchange of information
  • Clinical workflow  ability to automate the processes
  • Clinical decision support supports configuration of rules and alerts
  • Clinical documentation and data capture provides the ability to capture the information
  • Clinical display (plus dash board) presents data to enable effective usage
  • Order management – physician order entry, track status and view the results

Benefits of EMR

Medical Records Institute’s Survey of Electronic Medical Records Trends and Usage summarizes the benefits of EMR as:

Over and above facilitating care delivery process, EMR also enables clinical research. For example, post EMR implementation, Mayo Clinic has created a database of more than 4.3 million patient records. Physicians and Scientists can access this information through infinite number of unique queries across, 28 demographic elements, 523 DRG codes, 10,455 ICD-9 codes, 4900 laboratory test conditions. This is a valuable asset for research.

‘Though healthcare quickly embraces new technology related to diagnosis and treatment, it has been very slow to adopt IT advancements in the care delivery process’

Adoption of EMR

Having an EMR is seen as essential as an ATM is for a Bank. Patients will demand it. In spite of the benefits and demand from Patients, EMR adoption is yet to be taken up in many healthcare organizations. Many studies show that hospitals spend only 3 percent of their revenue on IT compared to other information intensive industries where IT spending is many times higher.

There are couple of reasons for it. First, the apprehension from the management: “does it benefit the investor of technology?” They perceive that new technology costs are shouldered by hospitals while the benefits both financial and non-financial primarily go to payers and patients. In other industries, the technology directly improves profitability of the entity that invests in the new technology. Secondly, for those who have invested, it continues to be a challenge to make the clinician to use the systems. The adoption of IT by clinicians is the key for success. The clinicians are reluctant because of usability issues.

Usability Defined

Following five parameters define the usability:

  • Utility – can be used to complete the desired task.
  • Goal / Task support – designed to complete task.
  • Accommodation designed to accommodate different user populations
  • Adoption  better than its competitor designs, therefore will be adopted by more users
  • Extensibility/ Adaptability has features that allow it to be adapted or extended to suit a new (unpredicted) task.

Usability in an application is incorporated through user-centered design methods but measured through the interaction of four components: Users, Applications, Requirements and Environment. Many IT enabled healthcare applications have failed in usability because of the lack of understanding of complexity in the environment.

Care Delivery Environment and the Delivery Process

Applications designed for conventional office like environment without taking into account some of the unique challenges of hospital work will not be successful. What makes a medical work fundamentally different from typical office work?

Let us look at the Steps in Care Delivery Process:

  • Obtaining patient history
  • Performing a physical examination
  • Ordering tests and uating their results
  • Establishing diagnoses
  • Prescribing therapies and monitoring the course of treatment.
  • Each step must be accurately documented

Clinical environment that influences the System Design:

Inherently Collaborative: Care delivery involves many specialists within the healthcare industry physicians, nurses, radiologists, pathologists etc.

Distributed: These specialists are at different locations and departments within the hospital, or outside, in different organizations

Interrupted: Clinicians are more frequently interrupted � by colleagues for adhoc co-operation, by patients needing immediate attention etc. This leads to clinicians more often suspending and later resuming their activities. More often they keep switching contexts.

Uncertainty and Dynamic Change: The patients’ response to treatment is fuzzy and can vary widely. This dictates a need for a relatively flexible process of patient management, where decisions are tentative and evolving based on a reinterpretation of previous data in the light of new information.

Information Intensive: Physicians meet patients in their office, attend patients at bed-side and respond to call-in patients. Each requires different ways of accessing information.

Multiple Care Settings: It is common for clinicians to work in multiple hospitals. They have to learn multiple applications to effectively function at different places.

Documentation Intensive: Near real-time documentation is the essential building block of healthcare processes.

For a successful adoption, EMR should be designed not solely by technology considerations, but should also take into account the above environment. In this article, we intend to focus only on the UI and data entry aspects.

Structured vs. Unstructured Data

In a typical hospital setting, physicians usually spend half their time on activities related to patient interviews, examinations and procedures, and the other half on reviewing and documenting records. Data entry to create all those documentations has always been a major obstacle to clinicians’ acceptance of EMR.

To simplify this data entry process, most applications provide Structured Data Entry (SDE), where the user has to select relevant clinical terms from a predefined list. In this paradigm, most of the functions required by the clinicians are just few clicks away. Though it sounds easier to do data entry through a few mouse clicks, it is not a most preferred method by Clinicians. To appreciate their perspective, we need to understand the clinical decision process.

Most medical interaction is driven by a conversational paradigm. Physicians listen to the patients, interview, instruct, counsel them etc. Narratives by the patients are at the heart of clinical decision making and this concept is referred as “narrative reasoning.”

Conversion of the narratives into a structure is a major challenge for clinicians. Extracting information from a narrative requires lots of work from clinicians. Medical narrative data are very diverse, and vary by discipline, patient, and over time and coding them to the “select” terminologies of the SDE paradigm is very restrictive.

Also, structured data can subtly change the meaning of the original item coded. Narrations could become a set of codes with weakly connected phrases without the semantic richness of the original content.

Patients’ clinical records should promote seamless transfer of care from one clinical team to another. This is best accomplished by sharing a narrative data and not just by structured data built using limited vocabulary of the application that too scattered around different screen pages.

Though structured data entry is essential for the uniform representation of data, easier reporting, decision support, quality assessment, and clinical research, etc., if we want clinicians to embrace the Electronic Medical Record, we must also make the unstructured narrative data entry as easy as possible.

Multimodal Interaction

W3C’s (World Wide Web Consortium) Multimodal Interaction Activity is developing specifications for extending the Web to support multiple modes of interactions. They are relevant in addressing the usability challenges in clinical applications.

Multimodal Interactions extend the user interface by offering users the choice of voice, keyboard, mouse, stylus or digital pen. For output, users will be able to read text, listen to spoken audio, and to view information on graphical displays.

Multimodal Systems are the systems that incorporate multimodal interaction through voice, handwriting, typing, etc. To address the usability issues, EMR should be a multimodal system.

Data entry through speech: Speech is natural and is also efficient most people can speak about five times faster than they type and probably ten times faster than they can write. In US, clinicians dictate their notes and get them transcribed by third parties. According to the American Medical Transcription Association, about $ 12 billion is spent each year to transcribe medical dictation into medical text.

EMR applications should enhance the UI with speech engine that seamlessly integrate digital dictation and speech recognition capabilities to simplify the data entry of narrative text. The converted text could be corrected through “self-edit” or “assisted -edit” mode.

Data Entry through Handwriting: In India, clinicians use handwritten records to document clinical notes. Digital pen-paper systems offer a convenient way of adapting that familiar handwriting mechanism into the EMR. It is a relatively cost-effective way for traditional paper processes to enter the digital world. The digital pen-paper captures the handwriting into an image and either it can be stored as an image in the EMR, without the benefits of search, analysis etc. or can be integrated with handwriting recognition engines to convert the handwritten notes into typewritten text. It also creates the conventional paper record either to share with patients or if required to have a paper trace. Digital pen-paper is less physically intrusive than data entry through keyboard.

Multimodal EMR should allow the users to input data with one or more modalities either in the sequential mode or composite mode. In the sequential mode, the user selects the modality and uses it to complete the transaction. In composite mode, even within a single transaction, the user can switch the modalities depending on the convenience and the need. For example, the user can start entering the text using key board, switch to digital pen-paper, switch to voice inputs and back to key board.

A multimodal EMR system will address all the concerns of clinicians from the data entry perspective.

Usability uation
Usability is now becoming an important software “quality” attribute. But can we measure usability? Are there metrics or checklists that can be used to uate the usability of a product / application? Fortunately Yes.

For Internet sites, it is a business imperative that the users can find the information they want quickly and efficiently. This is a challenging proposition since the users come from varied backgrounds and at varied levels of IT skills. The scientific structuring of the content and intuitive navigation for end user makes for a better user experience resulting in buying (revenue) and repeat visits (loyalty). The Usability Heuristics design rules of thumb, rooted in psychology, are used to develop and audit the Internet applications (see box).

‘EMR applications and implementations need to meet the tough demands of care delivery process and environment’

The EMR solutions trend being towards web applications, the same Usability Heuristics can be applied to EMR applications design. In the Healthcare domain, the users (clinicians) come from a more common social, economic and education background, but with varied level of IT skills.


The healthcare organisations are not enjoying the potential benefits of Electronic Medical Records (EMR) solutions. This is primarily due to adaptation issues of Clinicians. EMR applications and implementations need to meet the tough demands of care delivery process and environment. An EMR system that supports both structured and unstructured data capture with multimodal interactions and designed with usability heuristics should address the needs of clinicians and accelerate the deployment of EMR.


A heuristic uation is a usability uation method for application that helps to identify usability problems in the user interface (UI) design.

The following check-list can be used both by the application developers and by uators:

  • Consistency and standards: Users should not have to wonder whether different words, situations, or actions mean the same thing. Standards and
  • conventions in product design should be followed.
  • Visibility of system state: Users should always be informed of what is going on with the system through appropriate feedback and display of information.
  • Match between system and world: The image of the system perceived by users should match the model the users have.
  • Minimalist: Any extraneous information is a distraction and a slowdown.
  • Minimize memory load: Users should not be required to memorize a lot of information to carry out tasks. Memory load reduces users’ capacity to carry out the main tasks.
  • Informative feedback: Users should be given prompt and informative feedback about their actions.
  • Flexibility and efficiency: Users always learn and users are always different. Give users the flexibility of creating customization and shortcuts to accelerate their performance.
  • Good error messages: The messages should be informative enough such that users can understand the nature of errors, learn from errors, and recover from errors.
  • Prevent errors: It is always better to design interfaces that prevent errors from happening in the first place.
  • Clear closure: Every task has a beginning and an end. Users should be clearly notified about the completion of a task.
  • Reversible actions: Users should be allowed to recover from errors. Reversible actions also encourage exploratory learning.
  • Use users’ language: The language should be always presented in a form understandable by the intended users.
  • Users in control: Don’t give users the impression that they are controlled by the systems.
  • Help and documentation: Always provide help when needed.
  • Common user interface: Adapt standards wherever available. Reduces training while using multiple applications

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