MMHA 6600 Week 3 Pain Order Usability Review Example

Nine Clicks to a Dose: A Usability Review of the As-Needed Pain Medication Order Screen

Student Name

Walden University

MMHA 6600: Healthcare Informatics and Technology Management

Instructor Name

Month Day, Year

Nine Clicks to a Dose: A Usability Review of the As-Needed Pain Medication Order Screen

Scope and Approach

This review examines one screen in the electronic record at Bramble Creek Hospital, the invented 96-bed hospital that anchors this term's assignments: the order composer a prescriber uses to write an as-needed opioid for moderate or severe pain on an adult inpatient unit. The screen was chosen because the hospital's pharmacy logged repeated clarification calls about these orders, most often about missing pain-score ranges or duplicate orders with overlapping indications.

The review uses three methods suited to a single screen. First, a click-and-keystroke count for one standard order, completed by three prescribers. Second, a heuristic evaluation against established usability principles adapted for patient safety (Zhang et al., 2003). Third, observation of five orders written during real shifts, noting where attention was interrupted. The findings name design problems, not user errors, consistent with the view that usability failures in health records are properties of the system (Middleton et al., 2013).

The Task Measured

The standard order was oral oxycodone 5 milligrams, repeatable at four-hour intervals for pain scored 4 to 6, with a second order of 10 milligrams for pain scored 7 to 10, for a hypothetical adult patient with no renal impairment. This pair of orders is common on the unit and is the pattern pharmacy most often has to clarify.

Table 1

Interaction Count for One Paired As-Needed Order (Three Prescribers)

Writing one order takes nine clicks; the pair takes eighteen, and the whole sequence ran close to three minutes for every prescriber observed, even the fastest. The pain range, the piece pharmacy most often has to clarify, is the only part typed as free text.

Heuristic Findings

The screen was reviewed against principles adapted from Zhang et al. (2003), focusing on the five most relevant to ordering. Each finding is rated by likely severity for patient safety.

The default dose deserves particular attention. When a list opens on the higher strength, a hurried prescriber who accepts the default writes a larger dose than intended. Default settings shape choices strongly, and an analysis of vendor design processes found that user-centered testing of exactly these details was uneven across products (Ratwani et al., 2015).

Table 2

Heuristic Violations and Severity

Three high-severity findings share a theme: the screen does not help the prescriber build two orders that fit together, so the work of fitting them falls to memory and to pharmacy.

Where Attention Breaks

Observation of five real orders added what counts alone cannot. In three of five, the prescriber was interrupted between the first and second order, by a page or a nurse's question, and returned to write the second order without looking at the first. In two of those three, the pain ranges overlapped: one order covered 4 to 7 and the other 6 to 10. That overlap is exactly what generates pharmacy clarification calls, because a nurse facing a pain score of 6 has two valid orders.

The screen gives no help at the point of interruption. Nothing on the second order shows the first. The prescriber must remember it or reopen the active orders list, which takes three more clicks.

Recommendations

Four changes follow from the findings, and all can be made in the hospital's own order configuration:

First, add a structured pain-range field with two numeric boxes, replacing free text. Second, open the dose list with no default selected, so the prescriber must choose. Third, offer an order set for paired as-needed opioids that builds both orders on one screen with non-overlapping ranges filled in. Fourth, show any active as-needed opioid in a banner at the top of the composer.

Each change should be tested before go-live with three to five prescribers performing the same task, repeating the click count and asking them to think aloud. Small usability tests catch most serious problems at low cost, and testing after each configuration change is a recommended practice for organizations that build their own content (Middleton et al., 2013).

Expected Effect

If the order set works as intended, the paired order should fall from eighteen clicks to about eight and the free-text range should disappear. The measure that matters most, however, is the number of pharmacy clarification calls about as-needed opioid ranges, which pharmacy already logs. A fall in those calls over the following quarter would show the change worked; no change would suggest prescribers are working around the order set.

Limits

Three prescribers and five observed orders are a small sample, drawn from one unit on weekday shifts, and night prescribers may work differently. Heuristic review depends on reviewer judgment. The review examined one screen and did not assess how nurses read the resulting orders on the medication administration record, which would be a natural next study.

Conclusion

The as-needed pain order screen asks prescribers to build two orders that must fit together while giving them no help to make them fit. Structured ranges, no default dose, a paired order set and a visible banner move that work from memory to the screen. The change is small, local and testable, and pharmacy's own call log will show whether it succeeded.

References

Middleton, B., Bloomrosen, M., Dente, M. A., Hashmat, B., Koppel, R., Overhage, J. M., Payne, T. H., Rosenbloom, S. T., Weaver, C., & Zhang, J. (2013). Enhancing patient safety and quality of care by improving the usability of electronic health record systems: Recommendations from AMIA. Journal of the American Medical Informatics Association, 20(e1), e2-e8. https://doi.org/10.1136/amiajnl-2012-001458

Ratwani, R. M., Fairbanks, R. J., Hettinger, A. Z., & Benda, N. C. (2015). Electronic health record usability: Analysis of the user-centered design processes of eleven electronic health record vendors. Journal of the American Medical Informatics Association, 22(6), 1179-1182. https://doi.org/10.1093/jamia/ocv050

Zhang, J., Johnson, T. R., Patel, V. L., Paige, D. L., & Kubose, T. (2003). Using usability heuristics to evaluate patient safety of medical devices. Journal of Biomedical Informatics, 36(1-2), 23-30. https://doi.org/10.1016/S1532-0464(03)00060-1