Human Factors Engineering

Submitted by: Donna Baggetta, BA, Program Manager, Human Factors Engineering (HFE)

Published January 12, 2015.

Background

This scenario’s task list is extracted from the Summative Usability Test Plan for the VistA Evolution (VE) product. This test focused on the user interfaces for both clinicians (provider and nurse facing) and software system administrators (configuration specialist facing) on tasks that were part of the 2014 Edition EHR Certification for Meaningful Use (MU) from the Office of the National Coordinator (ONC) Health Information Technology (HIT) Certification Program. The primary purpose was to test and validate the safe, efficient and effective use with regard to the Safety-Enhanced Design (SED) criteria.

The usability Test Plan: It is important to realize that this test case description and list of tasks are only a small portion of a formal usability test plan. A formal plan may include “formative” testing activities that occur during software development, in addition to the “summative” testing that occurs on a completed, or nearly completed, product. A test plan may include multiple test cases in order to meet the scope of testing objectives. The goals of the test will drive the definition of the measures. Typical measures for summative testing include quantitative, such as time on task and number of errors, as well as qualitative with the participants stating their perceived level of difficulty of tasks. With a summative test case, it is common practice to not show the task description, or subsequent tasks until the participant is ready to perform the task and completes any prior tasks. Testing generally focuses on one task at a time, while others are ‘hidden’ from view, so that performance measures are collected and aligned to the specific task. For more details on how to establish a test plan, please review the National Institute of Standards and Technology (NIST) documentation NISTIR 7804 (technical evaluation, testing and validation of the usability of EHR) and NISTIR 7742 (template for EHR usability test reporting).

An interesting note for Test Case designers: Some testing criteria will be established by law, policy, or listed under contract requirements, and it is important to realize what ‘must’ be included compared to what is desirable to test.  Some test cases may be used to validate the summative performance of a contract deliverable, or ensure compliance with the law, and the requisite attention to specified requirements is expected. Other test cases may be used in a formative manner, to help improve the application’s functional utility and usability.

Tasks within the test cases are according to the user role, or the individual performing the task. A single user may perform tasks using multiple patients’ context within the same test case- but only for realistic tasks of their role. Don’t have Physician users perform unrealistic Clerical tasks. If transitioning to a new patient, provide the requisite information that informs the participant of the new context of use, or clearly indicate whether the context remains the same and what new information is present. This particular example is from the inpatient pharmacist’s perspective.

This effort describes the tasks performed evaluating the following MU criteria:

  • §170.314(a)(1)  Computerized provider order entry (CPOE)
  • §170.314(a)(2)  Drug-drug, drug-allergy (D-D & D-A) interaction checks
  • §170 314(a)(6)  Medication list
  • §170 314(a)(7)  Medication allergy list
  • §170.314(a)(8)  Clinical decision support (CDS)
  • §170.314(b)(3)  Electronic prescribing
  • §170.314(b)(4)  Clinical information reconciliation

Scenario Description

Task 1: Record orders for radiology/imaging

Patient Name: Test Data Patient Name

A 23-year-old male is admitted to the hospital after sustaining multiple injuries in a motor vehicle accident.  He has point tenderness on the lateral aspect of his left ankle and is unable to bear weight on his left foot due to the ankle pain. The admitting physician decides to order 3 view Left foot and 2 view Left ankle x-rays to rule out fracture.  As the inpatient pharmacist, please enter these orders into the VE product, and release them as Verbal or Telephone orders.

Current Medications: None

Allergies Reported: None

Task 2: Change a radiology/imaging order

(Continuation from Task 1 use case scenario)

After receiving a call from the radiology technician, you need to change the order for the Left ankle x-ray from 2 views to 3 views

Task 3: Access (view) the radiology/imaging orders

(Continuation from Tasks 1 and 2 use case scenarios)

Using the patient information from Tasks 1 and 2, check the VE product to ensure that the update to the patient’s Left Ankle X-ray imaging order is accurate, and the Left Foot X-ray order is accurate.

Task 4: Change and record a new order for medication, record new orders for lab

Patient Name: New Test Data Patient Name

A 49-year-old female patient is admitted to the hospital due to chest pains, lightheadedness, and headaches. She has adult onset diabetes mellitus and is insulin dependent, and she also suffers from anxiety.  While in inpatient, the attending physician orders a lipid panel.  The lab work shows that the patient’s total and LDL cholesterol are quite elevated.

Current Medications: She takes 10 units of long acting insulin glargine (Lantus) once daily to manage her diabetes, and lorazepam 0.5 mg tablet by mouth three times daily to manage her anxiety.  She has also been taking maximum dose simvastatin 80 mg by mouth once daily for 6 months for hypercholesterolemia.

Treatment Plan: The attending physician wants to change the dose of the patient’s inpatient medication from simvastatin 80 mg to atorvastatin 20mg by mouth daily hoping to achieve better control of cholesterol. The patient will also need lab orders for a Chem 7 panel and a Hemoglobin. As the inpatient pharmacist, please enter these orders using verbal or telephone orders.

Task 5: Change a Lab order

(Continuation from Task 4 use case scenario)

Use the same patient from Task 4. Upon reviewing the chart, you notice that you ordered a Hemoglobin, and not a Hemoglobin A1c. Change the order to a Hemoglobin A1c.

Task 6: Access orders for medication and lab

(Continuation from Tasks 4 and 5 use case scenarios)

Using the patient information from Task 5, check VE product to ensure that the update to the patient’s medication and lab orders is accurate.

Task 7: Record a new medication order and indicate Drug-Drug/Drug-Allergy Interventions

Patient Name: New Test Data Patient Name

A 68-year-old female patient was admitted to the hospital after complaints of chest pains and an irregular heartbeat. While inpatient, she has been diagnosed with paroxysmal atrial fibrillation and uncomplicated UTI.

Current Medications: She takes Aspirin 81mg by mouth daily due to a history of DVT. Allergies Reported: None

Treatment Plan: The attending physician decides to prescribe Bactrim DS (SULFAMETHOXAZOLE/TRIMETHOPRIM) 800mg/160mg mg by mouth po BID for the UTI. In view of her new onset atrial fibrillation, the attending physician chooses to initiate warfarin therapy with a starting dose of 2 mg by mouth daily.

The patient had an adverse reaction to warfarin six years ago when treated for a single episode of DVT (deep venous thrombosis). While inpatient, the patient forgets to tell you about the previous adverse reaction. As the inpatient pharmacist, please enter these orders.

Task 8: Record Patient Active Medication List

Patient Name: New Test Data Patient Name

A 57-year-old male who is admitted to the hospital after presenting to the emergency room with complaints of heart palpitations, dizziness, and headaches.  He has a history of diabetes mellitus, high cholesterol, high blood pressure, anxiety, and deep venous thrombosis.

As the inpatient pharmacist, please enter the patient’s inpatient medication orders.

Allergies Reported: None

Task 9: Change Patient Active Medication List

(Continuation from Task 8 use case scenario)

Use the same patient from Task 8. While inpatient, the admitting physician ordered Laboratory studies showing that the patient’s cholesterol was normal, but his hemoglobin A1C was elevated. The patient reports that in addition to taking his medication, he also has started a moderate daily exercise program of walking, and a low fat, low cholesterol diet, and he successfully has lost 5 pounds since his last doctor’s visit. The patient confesses that although he has been faithful to the low fat diet, he just cannot resist having some low fat sweet treats which he does consume on a daily basis and does not feel inclined to give that up.  Additionally, the patient complains of intermittent muscle cramping in the past few months that seems to be increasing in frequency.

Current Medications: The patient also complains that although his lorazepam is controlling his anxiety during the first half of the day, he becomes quite anxious by late afternoon and is quite uncomfortable getting through the afternoon and evening when he takes his second dose of lorazepam.

Treatment Plan: In view of the patient’s attention to diet and exercise, and in view of the muscle cramping, the attending physician decides to take this patient off simvastatin and monitor his cholesterol off the medication. To better manage the patient’s diabetes, the dosage of insulin glargine will be increased from 10 units per day to 20 units per day.

In response to the patient’s uncontrolled late afternoon anxiety, the frequency of lorazepam dosing will be increased from 0.5 mg tablet twice daily to 0.5 mg three times daily.  As the inpatient pharmacist, please enter the patient’s inpatient medication orders.

Task 10: Access the Patient’s Active Medication List and Medication History

(Continuation from Tasks 8 and 9 use case scenarios)

Use the same patient from Tasks 8 and 9 to make the following determinations:

* Is the patient currently prescribed simvastatin?

* Is the active lorazepam order for 3 times a day?

* Is the patient getting the new dose of Insulin?

Task 11: Record Patient’s Active Medication Allergy List

Patient Name: New Test Data Patient Name

A 78-year-old male is admitted to the hospital for a knee replacement.

Reported Allergies: He informs the admitting nurse that he is allergic to three medications – sulfasalazine, reaction: wheezing; penicillin, reaction: hives; and carbamazepine, reaction: skin rash.

Current Medications: None

As the inpatient pharmacist, please update this patient’s medication allergy list in VE Product.

Task 12: Change Patient’s Active Medication Allergy List

(Continuation from Task 11 use case scenario)

This task builds on the clinical information about the same patient from Task 11.  While reading some prior notes in the patient’s medical record, you discover that the patient did not have a prior allergic reaction to penicillin, but did have a reaction of hives when he was prescribed erythromycin in the past. Also, the patient is allergic to codeine rather than carbamazepine.  As the inpatient pharmacist, please update this patient’s medication allergy list in VE product to reflect these changes.

Task 13: Access Active Medication Allergy List and Medication Allergy History

(Continuation from Tasks 11 and 12 use case scenarios)

Use the same patient from Tasks 11 and 12 to make the following determinations:

* Is the patient’s allergy to Sulfasalazine active or inactive?

* What reaction does the patient have to Erythromycin?

* Is the patient allergic to Codeine?