Evidence-based usability design principles for medication alerting systems

Abstract

Background: Usability flaws in medication alerting systems may have a negative impact on clinical use and patient safety. In order to prevent the release of alerting systems that contain such flaws, it is necessary to provide designers and evaluators with evidence-based usability design principles. The objective of the present study was to develop a comprehensive, structured list of evidence-based usability design principles for medication alerting systems.

Methods: Nine sets of design principles for medication alerting systems were analyzed, summarized, and structured. We then matched the summarized principles with a list of usability flaws in order to determine the level of underlying evidence.

Results: Fifty-eight principles were summarized from the literature and two additional principles were defined, so that each flaw was matched with a principle. We organized the 60 summarized usability design principles into 6 meta-principles, 38 principles, and 16 sub-principles. Only 15 principles were not matched with a usability flaw. The 6 meta-principles respectively covered the improvement of the signal-to-noise ratio, the support for collaborative working, the fit with a clinician's workflow, the data display, the transparency of the alerting system, and the actionable tools to be provided within an alert.

Conclusions: It is possible to develop an evidence-based, structured, comprehensive list of usability design principles that are specific to medication alerting systems and are illustrated by the corresponding usability flaws. This list represents an improvement over the current literature. Each principle is now associated with the best available evidence of its violation. This knowledge may help to improve the usability of medication alerting systems and, ultimately, decrease the harmful consequences of the systems' usability flaws.

Keywords: Alerting system; Decision support; Design; Human engineering; Usability.

Fig. 1

Top: a graphical representation of the evidence-based usability knowledge framework. The numbering refers to the four steps, as described in the text. The question marks refer to the steps tackled in the present study. Bottom: an instance of the cause-consequence chain linking a usability flaw, a usage problem and a negative outcome (adapted from [27])

Fig. 2

Illustration of the matching process, using meta-principle E (#44) and one of its sub-principles (#48). The usability design principles found in the literature were summarized and organized hierarchically (left). The usability flaws identified in the systematic review were collated by topic (right). Next, the correspondence between a given type of flaw and a given summarized principle was established based on the principle’s ability (if applied) to fix the usability flaw. This correspondence is represented by a double arrow. When a usability flaw could not be fixed by any of the design principles in the literature, we either extended an existing principle or created a new one (single arrow). The illustration presents an extension of principle #48 (in italics)

Fig. 3

Sets of papers analyzed. Left: the set of papers analyzed to establish a structured list of usability design principles for medication alerting systems. Right: the set of papers analyzed to establish the list of usability flaws in medication alerting systems [17]

Fig. 4

Hierarchical organization of the meta-principles, principles, and sub-principles specifically related to medication alerting systems. Meta-principles are displayed at the top in colored boxes. Principles are presented in the linked colored boxes. Sub-principles are presented in the border-free areas below the principles

Fig. 5

Norman’s “seven stages of action” model, as applied to the interaction with a medication alerting system. Top: Loop a (on the left; “display/read” the alert) represents the core interaction. Loop b (“acknowledgement”) represents a second order interaction: not all alerting systems require alerts to be acknowledged. Usability design principles that could (if applied) improve the quality of the interaction are linked to the corresponding stage of the model, when possible