Sometimes, small tweaks can make a big difference, and according to Bob Hunchberger, a clinical informaticist for a 500-bed hospital, that couldn’t be truer when it comes to your EHR. 

Hunchberger suggests five dos and don’ts of EHR interface design. 

1. Don’t mix metaphors.  If the base metaphor you’re using is a tab metaphor taking you from function to function or page to page, said Hunchberger, stick with it. “Don’t switch metaphors within the application, requiring the user to remember to pick from a drop down list versus using tabs,” he said. “Also, make sure the tab metaphor looks like a real-world tab; users are easily confused about the use of tabs when they don’t look like real-world tabs.” If the metaphor is command buttons and links, he continued, then stick with it – don’t switch to graphic pictures with no command instruction on the picture, “or worse, use a picture that has no content in the mind of the user,” he said. Lastly, the same can be said when it comes to color metaphors, like the red, yellow, and green stoplight metaphor. Use them consistently, said Hunchberger, to indicate “high alert,” “warning,” or “everything is normal.” “Use of these colors to group tasks and/or medications in task lists or eMARs when they are not related to a high alert, warning or normal condition is poor use of the metaphor,” he said. 

2. Do minimize use of different colors.  Different colors distract, and too many colors are confusing, said Hunchberger. Instead, it’s best to keep it simple. “Trying to provide smart information through the use of colors can be overwhelming,” he said. “One color for one type of medication, and another for a different type, is poor use.” If you’re going to use color, remember to ensure that all information conveyed with color is also available without color.  “Why? Because about 8 percent of males and about one-half of 1 percent of females have difficulty discriminating colors,” he said. “When using colors to differentiate information in a grid or table, ensure a color code key is on the page and is easily understood so colors used on the page can be easily interpreted.” Finally, said Hunchberger, be consistent with the color palette. Don’t use 32-bit colors in one part of the application and the limited set of RGB colors in another.  

3. Don’t fail to provide short cut keys for experienced users. “Whatever happened to shortcut keys for experienced users?” said Hunchberger. “It seems that more and more EMRs are dropping smart keys or shortcut keys and requiring the user to move off the keyboard to the mouse. This is really annoying if all the entries require keyboard text entry.” Now, said Hunchberger, he has to slow down his data entry to move one hand off the keyboard, essentially eliminating half the characters he could use to enter information, until his hand comes back to the keyboard. And over the course of a day, he said, this can add up to minutes per person and hours in total lost time. “In a similar vein, if right mouse click options are provided for experienced users, ensure any fly-out option remains available, instead of having the user slide to the right or left to select,” he said. 

4. Do enable user preferences. Let the user determine how much support they want while they learn the application, said Hunchberger. “Just like the different learning models of visual, audible, and kinesthetic, the EMR should have personas that support the different learning styles that will make adoption much easier and safer,” he said. “Give the user the choice of persona they wish to use within the application.” Another example, said Hunchberger, is the use of grid controls or spreadsheet type layouts for data. If this action is going to be used, make sure it works like a spreadsheet. “Enable the end-user to adjust their column widths and row heights and allow them to save the setting rather than having to adjust the column widths each time they return to the page or window,” he said.

5. Don’t mix fonts and font sizes. Use sans-serif typeface styles; they’re easier to read in user interfaces because of the reduced dots per inch on a screen versus paper, said Hunchberger. “When a reader is expected to read text, make sure the text typeface is consistent from page to page and takes advantage of sentence capitalization,” he said. “Incorrect reading and visual interpretation of text is greatly reduced with consistent use of font size and spacing of characters.” He added end-user reading speeds are faster when fonts are used consistently, while individuals who read dark text on a white background can do so up to 32 percent faster than the inverse. “Use bold text sparingly and only when it’s necessary to draw attention to a piece of information or a word,” he said. “Changing the characters of a font from the surrounding text will draw the reader’s attention and slow reading speed. According to Microsoft, if you do only one thing [it should be to] respect the user’s settings by using the system font, sizes and colors.”

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