Usability Improvements to Electronic Health Records
Finding Realistic Paths to Success
Rebecca A. Meehan
School of Library and Information Science-Health Informatics, Kent State University, 1125 Risman, Kent, OH, U.S.A.
Keywords: Electronic Health Record, Usability, Information and Communication Technologies.
Abstract: There is a need to develop more effective strategies for improving usability within information and
communication technologies, specifically, electronic health record (EHR) systems. Usability incorporates
the ease of use, learnability, efficiency, effectiveness and satisfaction of a system by the end user. When an
EHR incorporates principles of usability, the system does a better job of meeting the needs of the end users
intuitively, resulting in fewer errors and better quality outcomes for patients. Health systems and
governments have been urging the widespread adoption of EHR systems to help lower costs and increase
efficiency, putting themselves and vendors under pressure to develop and implement the best solution
quickly. Too often stakeholders rely on future releases and enhancements to fix issues not originally
planned for in the initial release of the product. Hospital system end users and vendors need better strategies
for improving usability in EHR solutions. Poor usability can result in frustrated end-users, inefficient and
more costly processes, and, at worst, compromises to patient safety. Proposed strategies and areas for future
development are discussed.
1 INTRODUCTION
Problem statement
There is a need to develop more effective strategies
for improving usability within information and
communication technologies, including electronic
health record (EHR) systems. Each stakeholder
involved in developing and using the EHR has an
opportunity to improve its usability. This position
paper focuses on ways to learn and understand more
from EHR vendors about the best ways to improve
usability. Many EHR vendors that incorporate user
centered design and usability principles into their
software development lifecycle (SDLC) are
generally among the most successful solutions.
Because of the impact of usability on quality of care
and patient health, it is important for all EHR
vendors to have strategies for incorporating usability
into the built product. Too often, there are
communication barriers among a vendor’s internal
stakeholder groups of product development,
usability/user experience, product management,
sales, support and implementtation. It is critical for
the executive team to prioritize usability in the EHR
product roadmap, and to facilitate communication
among the internal vendor stakeholders. Some
techniques and processes are better than others for
making the products more user-friendly. And as
SDLC processes change, so too, must the strategies
for incorporating iterative feedback on usability.
All EHR stakeholder groups (e.g. hospitals,
clinicians, vendors) need to identify the most
effective and affordable ways to incorporate
usability principles into their EHR products. This
paper focuses on the vendor as a stakeholder, and
helps to identify ways to incorporate usability into
the SDLC. To address the issue, vendors can turn to
usability consultants, or have their own staff
implement best practices outlined in professional
reports. These reports that help to identify usability
best practices and design heuristics stem from efforts
made in the academic, industry standards,
government, non-government organizations, and
professional associations. Some of these include
HIMSS, HL-7, NIST, EHRA of HIMSS, AMIA, and
IHE. Likewise, there are many academic efforts and
studies focused on identifying best practices in
usability standards. The challenge is that these
groups, as well as HIT software development
514
Meehan R..
Usability Improvements to Electronic Health Records - Finding Realistic Paths to Success.
DOI: 10.5220/0005252705140518
In Proceedings of the International Conference on Health Informatics (HEALTHINF-2015), pages 514-518
ISBN: 978-989-758-068-0
Copyright
c
2015 SCITEPRESS (Science and Technology Publications, Lda.)
organizations tend to present information in “siloes.”
That is, the best practices tend to stand alone, and do
not easily find their way into the EHR product.
Central to this issue is a lack of a common language.
Because standards groups or academic usability
experts are not typically on site or embedded with
product developers or product managers, it is
challenging to find the most effective ways to
communicate about usability problems, and to
collaboratively solve problems that arise. This
barrier makes it difficult to implement the expert
advice into the SDLC and overall process. While the
“silos” may be unintended, they prevent the
exchange of pertinent information. What is needed is
a common language and common purpose to
integrate usability guidelines and user centered
design into EHR systems. It is essential that each of
the groups mentioned here continue to do the hard
work they are currently doing in advancing usability
principles and their incorporation into EHR systems.
This position paper proposes a strategy to
evaluate vendor strengths, and to identify common
goals and obstacles. This paper proposes a pilot
study to explore ways to facilitate best practices for
integrating usability principles into EHR systems.
While the proposed study focuses on vendors, the
collective stakeholder group, comprised of EHR
clients (e.g. hospitals, clinicians), standards
organizations, caregivers, patients, and payers, is
critical in identifying optimal solutions for
improving usability, and ultimately improving
patient health outcomes. Findings from this study
will serve as a foundation for identifying a common
language and goals that each stakeholder group has
in common. The goal of the study will be to work
specifically with EHR developers and vendors to
understand how usability is considered and handled
in their existing strategies and work to build best
practice techniques going forward.
2 BACKGROUND
The U.S. healthcare system is undergoing a
technological transformation fueled in large part by
the wide spread adoption of electronic health record
(EHR) systems. The implementation and use of
EHR systems has been accelerated by financial
incentive programs initiated in the American
Recovery and Reinvestment Act –Health
Information Technology for Economic and Clinical
Health Act (HITECH) (2009) as well as the
expanded innovative care delivery and payment
models specified under the Affordable Care Act
(2010). Eligible hospitals and providers are seeking
to implement EHR systems in a timely fashion,
enabling them to take advantage of the financial
incentive programs of “meaningful use.” This
market demand for EHR systems and rapid pace of
adoption and implementation leaves little time for
improving usability.
2.1 What Is Usability?
The International Organization for Standardization
(ISO) defines usability as the effectiveness,
efficiency, and satisfaction with which the intended
users can achieve their tasks in the intended context
of product use (ISO/IEC, 1998). The TURF
(Toward a Unified Framework of EHR Usability)
initiative (Zhang and Walji, 2011) defines usability
as how useful, usable, and satisfying a system is for
the intended users to accomplish goals in the work
domain by performing certain sequences of tasks.
The TURF approach advances the practical science
of usability in that it proposes a unified scientific
framework under which usability can be considered.
Moreover, it is a method by which usability can be
measured objectively and systematically. A few
common examples of usability problems include a)
patient identification error: actions intended for one
patient are documented in the record of another
patient; b) data availability error: decisions should
not be based on incomplete information, because the
user does not have pertinent information on the
screen (e.g. allergy to medication), and the user
would need to take extra navigation steps to find the
pertinent information; and c) match: the system
should follow the users’ language with words,
phrases and concepts familiar to the user and not
system based (e.g. labels should convey meaningful
actions to the users).
Usability testing will not be effective if
conducted by only one stakeholder. A collaborative
model is necessary. The client or hospital system
implementing the EHR should participate in product
design and iterative testing throughout the SDLC.
Ideally, the client would participate in both early
stage (formative) usability tests and in later stage
(summative) testing. Formative usability testing
occurs early during the formation of the software to
inform and verify design decisions and to understand
what is not usable (www.usability.gov). It tends to
be qualitative feedback from end users about the
UsabilityImprovementstoElectronicHealthRecords-FindingRealisticPathstoSuccess
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functionality and behavior of the software. At early
stages, users are generally asked to identify
workflows, evaluate information architecture,
language, and icons. Ideally, formative testing is
iterative, and done frequently within the software
development lifecycle. In contrast, summative
usability testing evaluates the user interface of
software in its current form. Different usability
evaluation techniques are used in summative testing.
For example, efficacy tests, or time task tests (the
time it takes a user to complete a certain task), and
user satisfaction can all be evaluated at this stage.
The goal of summative testing is to identify and rate
the usefulness of the interface, while providing
quantitative and qualitative feedback to the vendor
or internal engineering team on elements that need
to be fixed or enhanced. Some outcomes may be
issues of configuration, in which the implementation
team can work with to refine the parameters of
configuration, as opposed to a product change.
2.2 Why Is Usability Important?
Systems incorporating a user centered design, with
high levels of usability have been shown to support
clinician users in their workflow and help to increase
quality outcomes for patients (Garg, et al, 2005;
Chaudry, et al 2006; Bates, 2005). Conversely, a
lack of usability in the EHR has been associated
with unintended consequences, including harm to
patients (Campbell, et al, 2007).
EHR usability is a common complaint heard
among clinicians from hospital systems and
practices. HIMSS (2009) reports that usability is one
of the primary reasons, “possibly the most important
factor” hindering widespread adoption of EHRs
(http://www.himss.org/files/HIMSSorg/content/files/
himss_definingandtestingemrusability.pdf).
The HIMSS article describes that usability has a
strong, often direct relationship with clinical
productivity, error rate, user fatigue, and user
satisfaction, all important factors for EHR adoption.
Days spent for EHR training, while necessary, put
clinicians in a position to lose productivity.
Moreover, the months after a new HIT adoption,
clinicians need to adapt to the new tools and
workflow.
2.3 Market Demand
Despite the challenges of working with new EHR
systems that have improvements to be made in
usability, the “meaningful use” financial incentives
in the U.S. have kept the market demand high for
implementing an EHR system. In 2013, nearly six
in ten (59%) non-federal acute care hospitals had
adopted at least a basic EHR system with clinician
notes. (Charles, et al, 2014). This represents a 5-fold
increase in EHR adoption among U.S. hospitals
from 2008- 2013. Moreover, Charles and colleagues
(2014) report that 93% of hospitals possessed a
certified EHR technology, increasing 29% from
2011. Office based providers are also quickly
adopting EHR systems. A 2014 National Center for
Health Statistics report indicates that in the U.S. in
2013 over 78% of office based physicians used any
type of EHR system (Hsiao and Chung, 2014). This
statistic is up 18% from 2001. Further, the report
indicates that 69% of office based physicians plan to
participate in meaningful use incentives. This rapid
acceleration of EHR adoption in hospital systems
and physician offices puts a strain on end users,
implementers, and vendors to increase EHR
usability. At worst, the delay for EHR usability
enables increased medical error and unintended
consequences for patient outcomes. At best, as EHR
usability lags behind, so does the opportunity to
promote the end user experience, enabling the EHR
to be a catalyst for improved patient care and
wellness. We need to find better strategies for
usability to make it into the built EHR system.
2.4 Influence of the Organization
As we discuss the challenges to incorporating
usability into the EHR systems, in a fast-paced high
market-demand environment, it is important to
provide a context into which the systems will be
implemented and utilized. According the U.S.
government’s website “HealthIT.gov” (www.
healthit.gov), Peter Drucker, called health care
workplaces "the most complex human organiza-
tion[s] ever devised." Interactions between the
complex environments of health care workplaces
and increasingly complex EHRs can result in subtle
unintended consequences of EHR implementation.
The interactions between the EHR and the work
environment or between the EHR and the technical
and physical infrastructure can result in problematic
consequences, but not necessarily from any product
malfunction. The flow of interactions between the
HIT and the healthcare organization’s sociotechnical
system—its workflows, culture, social interactions,
and technologies can result in unintended and
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undesired consequences of HIT (Harrison, et al,
2007). This research by Harrison and colleagues
(2007) delineates a conceptual model of the
Interactive Sociotechnical Analysis (ISTA), that
captures common types of interaction with special
emphasis on recursive processes, i.e., feedback loops
that alter the newly introduced HIT and promote
second-level changes in the social system. Usability
design strategies at the vendor level need to be
informed by how the product will be implemented,
utilized and transformed when it is used in the
hospital or clinician office. As vendors prepare their
usability strategies for both formative and
summative usability testing, the ISTA model
provides a context to interpret user feedback for both
fixes in the short term and future release
enhancements in the long term.
3 A PROPOSAL FOR SOLUTIONS
Before a recommendation for improvement on
usability practices can be made, it is important to
understand how vendors currently define and work
with usability. Specifically, it is important to know
how internal stakeholders in product development
are communicating about usability. In order to
understand how EHR software developers and
product managers currently incorporate usability
into their products, I am proposing a study to
interview a representative sample of EHR
developers and product managers. Methodolo-
gically, the study will use a Delphi process. Hsu and
Sanford (2007) describe the Delphi technique as a
widely used and accepted method for achieving
convergence of opinion concerning real-world
knowledge solicited from experts within certain
topic areas. Their work describes the technique is
used as a group communication process that aims at
conducting detailed examinations and discussions of
a specific issue for the purpose of goal setting and
policy investigation. The Delphi technique is used
as a method to identify among experts in a field,
what ‘should’ be (Miller, 2006).
The proposed study will used a mixed method
approach. The Delphi process will facilitate
identifying what should/could be in the future as far
as best practices. This will be combined with a
semi-structured 1:1 interview of product developers
and managers to understand current practices,
language and communication processes.
Specifically questions will be asked in the
following areas:
a. How do you define usability?
b. How do you currently prioritize usability?
c. Are principles of usability part of the non-
functional requirements for the product?
d. Does anyone discuss or email about how to
incorporate usability or why it is important?
Who? How often?
e. How would you like to/ should you prioritize
usability?
f. How do you currently incorporate usability
principles into your product set?
g. How would you like to/ should you
incorporate usability?
h. If yes, then what is the timing or at what
point in the software development lifecycle it
is incorporated?
i. If yes, then how could you like to/should you
modify the timing of when usability is
incorporated?
j. What would you recommend in terms of
strategy for incorporating usability into their
products?
k. In terms of your internal process with
usability, what is working, what is not
working, what can be improved?
l. What is the biggest challenge you have in
incorporating usability?
m. When did this work well? Why?
Findings from this study will be used to identify
best practices for EHR vendor product development
teams. Moreover, findings will be used to help
improve communication and strategies between
vendors and their clients for evaluating usability to
improve the product, implementation and overall
experience.
4 CONCLUSIONS
It is imperative to find new, more realistic, strategies
of incorporating usability into EHR systems. This
project focuses on one of the EHR stakeholder
groups, and proposes a way to improve usability
strategies among the people who literally build the
product: product developers within EHR vendors.
The EHR provides tremendous opportunities to
improve efficiency and effectiveness for health care
providers. Ultimately, the advances created in the
EHR systems allow for better medical care and
UsabilityImprovementstoElectronicHealthRecords-FindingRealisticPathstoSuccess
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better health outcomes for patients. These
improvements will be incremental, and they will not
be without complexity. In order to realize the
potential of EHR systems, it is critical that the EHR
employs user center design and usability strategies
in the early parts of the software development
lifecycle. This will result in a system that is easier
to use and intuitive. In order to improve usability
in EHR systems, all stakeholders need to make
efforts to break down the silos of information and
identify and use a common language toward
achieving a unified goal of optimal health outcomes
for patients. Only then can a realistic solution be
achieved. The proposed project represents an effort
to identify that common language and shared vision
among EHR developers and users.
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