Imagine a complex system with many different users, used in many environments, to support a continuum of activities from health and wellness to sickness to life and death emergencies. The system is the patient medical record. In today’s healthcare domain the patient medical record, more commonly known as the electronic medical record (EMR), or the broader version, the electronic health record (EHR), is in the spotlight.
No matter what view you take of healthcare, you are going to find the EHR.
Take the view of healthcare reform. The goals of healthcare reform are to make healthcare more affordable, hold insurers more accountable, expand coverage to all Americans and make the health system sustainable. The means to achieving this goal includes building systems that are used to document the medical treatment a patient receives, systems that talk to each other, and systems that improve quality of care that individual patients and populations of patients receive. One of those systems is the EHR.1
Take the view of healthcare privacy and security. The Office for Civil Rights is responsible for protecting the privacy of our individually identifiable health information, HIPPA. This same office is responsible for setting national standards for the security of electronic protected health information. Those national standards are created and applied to the design, development, and use of EHRs so that a patient’s medical history, symptoms, diagnoses and treatments are only shared with appropriate clinicians and only shared with people that patients give permission.2
Take the view of interoperability (information exchange). The Office of the National Coordinator (ONC) is the government agency inside of Health and Human Services (a government agency) that is responsible for healthcare information technology. One of ONC’s Health Information Technology for Economic and Clinical Health (HITECH) programs is focused on building the infrastructure so that the secure exchange of health information can take place with the goal of improved clinical care and reducing cost. That health information is the data in the patient’s EHR.3
Who are the users of the EHR? Doctors, nurses, specialists, medical technicians, and patients, to name a few, are. For simplicity, let’s focus on doctors. Not all doctors are using EHRs. With the promise of patient data in an electronic format that is easily shared…patient data that can be searched, reviewed, graphed, manipulated, and studied in order to provide better quality of care… patient data that is easily portable so that when a patient changes doctors, moves or becomes ill while on vacation … a means by which the current doctor knows all the important medical information about the patient. Why wouldn’t a doctor use such a system?
A number of reasons have been suggested to explain why doctors are not adopting and using of EHRs. One of those reasons is lack of usability.
Usability is defined as the efficiency, effectiveness, and satisfaction with which a specific user can complete a specific task.
EHRs lack USABILITY. Most EHRs are inefficient systems. Many EHRs are ineffective in some capacity. And users (doctors, nurses, specialists, medical technicians, patients, to name a few) are not satisfied with EHRs.
Doctors describe and user researchers observe that many EHRs add hours of work to the doctor’s work day. In some EHRs it might take:
- 10 mouse clicks to indicate “right hand,”
- 5 additional clicks to indicate skin (as opposed to bone),
- 3 clicks to get to place in the user interface to indicate rash,
- 3 clicks to indicate “severe”,
- 3 clicks to indicate “longer than one week”,
- 3 clicks to indicate “red and swollen”,
- 3 clicks and typing “2” to indicate a 2 inch area.
Adding the clicks: 10 + 5+ 3 + 3 + 3 + 3 + 3 = too many clicks.
Too many clicks in an era where the doctor should be able to click the right hand in a graphic of the body or where the doctor should be able to snap a picture to document a severe rash on the right hand.
The lack of effectiveness of EHRS is seen in a number of areas. Effective EHRs will talk with other systems. However, many EHRs in a doctor’s office don’t talk to the EHR used at the local hospital. But let’s highlight another component of effectiveness. EHRs carry the promise of improved quality of care.
According to Jeff Shuren5, from January 2008 to December 2010, the FDA received approximately 370 reports of adverse events or near misses related to healthcare information technology including EHRs. This number grossly underestimates the actual number of events that actually occur for a number of reasons; there is not a common reporting system for such errors, the FDA does not control or regulate EHRs, many EHR companies make EHR purchasers agree not to report or talk about the relationship of the EHR to an adverse event6.
These reports of the adverse events were associated to EHRs in the following ways:
- failure to adequately address interoperability with other technologies,
- user error,
- inadequate workplace practices,
- design flaws,
- failure to properly test the technology prior to distribution, upon installation or during maintenance (such as validation testing),
- or failure to adequately address problems that can arise when people interface with machines.5
In terms of satisfaction:
- Added hours to the end of the work day,
- multiple log ins into multiple systems that don’t talk to each other,
- too many clicks,
- potential errors if “I” am not thinking about the software--
…where is there satisfaction?
EHRs are in the spotlight… within the spotlight is a movement to improve the usability of EHRs. There are many avenues and opportunities to improve the usability of EHRs. Many of the companies that make EHRs are learning about usability and applying user centered design activities to improve the usability of an EHR. Physician practices and hospitals are including usability requirements in Requests for Proposals and procurement guidelines for EHRs. In addition, physician practices and hospitals are learning the value of conducting usability tests to inform purchase decisions. Professional organizations (e.g., Health Information Management Systems Society7 (HIMSS) and physician academies (e.g., Academy of Family Physicians) are educating their members about usability. Even the government is getting involved with the movement to improve the usability of EHRs. The ONC has described that usability will be included as criteria in the ONC’s Meaningful Use program and the National Institute for Standards and Technology (NIST) recently released their proposed EHR Usability Evaluation Protocol8 which in some way yet to be defined will be the usability test method by which EHR usability will be measured according to the government.
The usability of EHRs is in the spotlight. As usability professionals and patients, be proactive in assuring that the tools used to keep us healthy, to heal us in time of sickness and to help us survive life and death emergencies are efficient, effective, and satisfying…that EHRs are systems characterized by high usability!
About the author
Janey Barnes, PhD is a principal and human factors specialist at User-View, Inc. Janey is responsible for obtaining and managing projects and conducting state of the art user-centered design and evaluation for client programs. She has developed and taught human factors courses at universities and for professional organizations. Janey is affiliated with several professional organizations and participates in these organizations by making presentations and teaching workshops. Janey is active in the HIMSS Usability Taskforce. She is currently serving as the 2011 chair of the taskforce. In addition, Janey serves on the TriangleUPA Advisory Board.
1 http://www.whitehouse.gov/healthreform, accessed July 7, 2011.
2 http://www.hhs.gov/ocr/privacy/, accessed July 7, 2011.
3 http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__hitech_programs/1487, accessed July 7, 2011.
4 https://www.cms.gov/ehrincentiveprograms/, accessed July 7, 2011.
5 http://www.iom.edu/~/media/Files/Activity%20Files/Quality/PatientSafetyHIT/Meeting%201/Jeff%20Shuren%20-%20Oral%20Statement%20to%20the%20IOM.pdf, accessed July 7, 2011.
6 Ross Koppel, David Kreda (2009), Health Care Information Technology Vendors' “Hold Harmless” Clause: Implications for Patients and Clinicians, JAMA.; 301(12):1276-1278.
7 http://www.himss.org/ASP/topics_FocusDynamic.asp?faid=358, accessed July 7, 2011.
8 http://www.nist.gov/healthcare/usability/usability-technical-workshop.cfm, accessed July 7, 2011