Playing out an EHR usability appraisal can bolster viable
EHR optimization ventures for healthcare organizations.
10 years after the HITECH Act of 2009 first boosted EHR
adoption, numerous physicians stay disappointed with EHR design and are looking
for improvements to EHR usability. This is where a EHR system with a cognitive design can help.
Upgrading an EHR with the goal that it offers natural,
streamlined workflows is basic for advancing clinical effectiveness and
lessening provider load. Shortening the measure of time clinicians spend
filtering through patient data and exploring the EHR interface can eliminate unproductive keyboard time and enable providers to invest more energy
cooperating eye to eye with patients.
Given that most physicians refer to the patient-provider
relationship as their essential wellspring of profession satisfaction with their careers, moving
the concentrate far from EHR data passage is a top need for healthcare
administration.
Increasingly instinctive EHR interfaces may likewise
demonstrate to be a shelter to patient well-being, as indicated by a 2018 JAMA research report. Researchers discovered issues with EHR usability may add to
episodes of patient damage. Moreover, inquiry about proposed rates of patient satisfaction decreased when providers spend a noteworthy extent of the patient
experience pondering over EHR systems.
Searching for ONC-certified health IT systems amid the EHR
selection procedure can give healthcare authority some confirmation that a health
IT system will have buyers confronting highlights proposed to help usability.
Certified EHR technology innovation (CEHRT) must experience a pattern dimension
of EHR usability testing so as to acquire affirmation.
Nonetheless, some healthcare industry partners have
contended that the usability testing segment of the ONC Health IT Certification
Program needs thoroughness and neglects to assess usefulness all through the
EHR life-cycle.
Directing an EHR usability appraisal post-execution can help
healthcare organizations evaluate the proficiency and adequacy of their EHR
innovation, develop workflows that meet their particular needs, and pinpoint
open doors for improving user fulfilment.
WHAT IS EHR USABILITY?
HIMSS characterizes EHR usability as "the adequacy,
effectiveness and fulfilment with which explicit users can accomplish a
particular arrangement of tasks in a specific environment."
The "usability" of a specific system can be
surveyed by recognizing how well it meets criteria in nine key classes.
Simplicity
A basically designed EHR interface does exclude information
or visual components that are pointless for finishing administrative or
clinical tasks. Straightforward interfaces lessen the probability physicians
will be overpowered by the measure of data showing up on their screens.
EHR systems are designed in view of reducing the effort like
featuring significant information utilizing obvious prompts and incorporating alternatives
that are straightforward. Featuring key information enables providers to
discover pertinent data all the more rapidly. The design of the interface
itself is clear, clean, and uncluttered.
Regular and Natural
As per HIMSS, regular EHR interfaces ought to incorporate
"screen representations that are well-known to regular day to day existence,
or ordinarily expected PC encounters for the clinician."
Clinical workflows in a characteristic EHR interface are
explicit to the necessities of clinicians. The interface is likewise natural
and simple to figure out how to confine the weight of EHR training.
Consistency
In a predictable comprehensive EHR interface, all pieces of the
application have a similar look and feel. Phrasing and data passage fields are
additionally utilized and put reliably, and providers can move flawlessly
through various workflows. Steady EHR interfaces advance congruity and decrease
disarray for providers.
Forgiveness and feedback
Data section blunders are common. In the event that
providers commit an error inside the system, a generous application enables
users to recuperate from mistakes effectively. The system additionally gives
proper and non-noisy feedback to the user about activities they are going to
take or have officially taken to diminish the probability a user will make an
unintended move.
The system additionally advises users on the extent a move
will make, and clears up the motivation behind the activity.
Effective utilization of language
Language utilized inside shopper benevolent EHR systems
mirrors words clinicians use in practice, while additionally giving mapping to
standardize codes and terms for data recovery. Rundown and section structure
decisions are unambiguous. In general, language inside the EHR interface should
peruse like common English.
Productive interactions
An EHR system that empowers productive interactions is
designed to limit the number of steps or clicks required to finish tasks.
A productive EHR system additionally offers a wide range of
navigation choices, for example, shortcuts for experienced users to minimize
the interaction time. Navigation techniques limit the requirement for user
developments including looking over and exchanging among composing and clicking
the mouse to streamline EHR use for clinicians.
Effective information presentation
The design of the EHR interface utilizes clear textual
styles and outwardly engaging components to enable users to effortlessly devour
information.
High-value data or unusual values for clinical data are
featured or introduced here and there that passes on importance. For instance,
a system may utilize red content or pictures to flag that a data component is
anomalous and should be tended to desperately.
Preservation of continuity
The EHR interface incorporates insignificant screen changes
and visual interference while providers are finishing tasks, enabling users to
concentrate on the substance of the work process as opposed to adjusting to
another environment after each activity.
Minimized Cognitive Load
To limit intellectual burden, EHR data ought to be firmly
organized by task without expecting users to get to various screens at the same
time.
EHR alarms ought to be succinct, useful, and suitable.
Guaranteeing EHR cautions are just utilized in high-sway circumstances
decreases the probability of EHR ready weariness, which can represent a danger
to patient well being now and again.
A purchaser neighbourly EHR system likewise performs
computations consequently for providers to lessen psychological burden and
anticipate human mistake.
Deciding if an EHR system has these characteristics can be a
test given the subjectivity of user experience. In any case, healthcare
organizations can work off industry inquire about while recognizing potential
roads for leading a complete EHR usability evaluation amid and after execution.
KEY CONCEPTS TO CONSIDER BEFORE LAUNCHING EHR USABILITY
ASSESSMENTS
Health IT developers and healthcare organizations settle on
choices all through the EHR life-cycle that influence a system's level of
usability.
Government controllers, for example, ONC can test an EHR
system's presentation against key measurements preceding usage, however the
onus falls on healthcare organizations to decide if a system addresses the
issues of its providers and novel environment.
In a 2018 report, Pew Charitable Trusts, AMA, and MedStar
Health's National Center for Human Factors in Healthcare distinguished various
ways healthcare organizations can guarantee EHR usability testing precisely
assesses a wide scope of usefulness and potential situations.
Initially, the organizations proposed healthcare
administration consider every key task when arranging an EHR usability
appraisal.
"Developer usability testing performed for
accreditation centers around EHR capacities required by ONC," composed the
organizations. "A few vendors develop experiments that incorporate tasks
to assess well-being, however this practice isn't inescapable. Experiments ought
to likewise concentrate on progressively key tasks in which the utilization of
these systems can influence well-being."
The organizations likewise exhorted that an EHR usability
evaluation be illustrative of the essential end-user, regardless of whether
that is a medical attendant, a physician, or another certified staff part.
"Whenever possible, speak to finish workflows that
include numerous kinds of clinicians taking an interest in the situation at the
same time," the report exhorted.
As a major aspect of guaranteeing EHR usability evaluations
are illustrative of a healthcare association's end users, Pew suggests
healthcare organizations think about the demands of its clinical workflows,
environment, and any EHR-coordinated outsider innovations. Healthcare
organizations may likewise need to guarantee usability appraisals are
clinically important.
Seat and its accomplices additionally focused on that
surveying EHR usability at normal interim is fundamental for precisely
measuring EHR usefulness.
"Different phases of the product life cycle, including
how the product is altered by health care facilities and how software redesigns
are executed, can show distinctive usability and well-being challenges,"
the organizations composed.
At long last, Pew and its accomplices proposed healthcare
organizations consider the socio-specialized environment of their office while
evaluating the proficiency and adequacy of EHR highlights.
"Confirmation testing, directed before execution in
healthcare facilities, centers around the discharged EHR product and may not
control for different components that can impact security," the
organizations forewarned. "For instance, the sort of preparations
clinicians get decides their insight into the EHR's highlights, including how
to arrange drugs, symptomatic pictures, and lab tests effectively and
securely."
"Furthermore, the healthcare office may settle on
choices amid EHR usage about how to organize information in the system, which
influences how clinicians connect with the innovation," the creators
proceeded.
In view of these ideas, healthcare organizations can
distinguish solid objectives and measures for a meaningful EHR usability
appraisal.
Pew and its partners suggest that healthcare organizations
recognize solid objectives and measures that target a particular objective
before starting assessments. Also, the organizations proposed healthcare
association initiatives guaranteed experiments are reproducible and
unambiguous.
“Developing and using test cases that adhere to these
criteria will provide greater rigour to the evaluation of clinician interaction
with EHRs and can serve to better highlight specific usability and safety
challenges in the design, customization, or use of products before patients are
harmed,” advised authors in the report.
EHR USABILITY TESTING METHODS FOR HEALTHCARE ORGANIZATIONS
HIMSS categorizes EHR usability testing in one of the two
ways: formative and summative.
Health IT developers are responsible for formative testing.
Formative testing includes activities that help developers understand the user
and clinical workflows, make iterative improvements to the product, and design
the EHR interface in accordance with user needs.
Healthcare organizations perform summative testing.
Summative EHR usability activities include expert review, performance testing,
risk assessment, and one-on-one usability testing.
In combination, these activities can help healthcare
providers evaluate efficiency, effectiveness, cognitive load, and other
principles of EHR usability.
HIMSS recommends healthcare organizations test aspects of
EHR usability in the following ways:
Efficiency
Expert review and one-on-one usability testing can be
effective in measuring efficiency, according to HIMSS.
One-on-one usability testing can be performed in conjunction
with an expert, intermediate, or novice end user. In one-on-one usability
testing, end users are prompted to complete key tasks within the EHR interface
and collect performance data during each task.
“Expert review is a human factors expert review of the
product,” wrote HIMSS. “As part of the review, usability specialists identified
areas in the product where the product conforms or fails to conform to Human
Factors' best practices.”
One-on-one usability testing requires close monitoring to
ensure performance data is accurately recorded.
“Sessions are frequently recorded with special software that
captures interactions with the graphical user interfaces and matches the
interactions with time stamps,” stated HIMSS.
Users can record key indicators such as the time it takes to
perform a particular task, the number of interactions necessary to complete the
task, the number of screens visited to complete a scenario within clinical
workflows, the number of times the ‘back’ button is used, and the time it takes
to complete a set of instructions within the EHR system.
In 2017, Arcadia Healthcare Solutions measured the number of clicks a single provider needed to complete her clinical and administrative
tasks throughout an average workday.
According to Arcadia Healthcare Solution’s research, the
clinician needed 2,541 clicks to document 24 patient encounters over the course
of a 16-hour workday.
The results confirm provider concerns that EHR interfaces
lack efficiency and require providers to perform a high number of interactions
to fulfil reporting requirements and complete clinical documentation.
Recording the amount of time providers spend completing
tasks within the EHR can help healthcare organizations identify particularly
labor-intensive aspects of clinical documentation to guide workflow
optimization.
Organizations that undertake similar examinations of routine
EHR use may be able to identify areas for improvement or new workflow
strategies that minimize cognitive fatigue.
Effectiveness
Risk analysis exercises are helpful for determining a
system’s ability to avoid errors when completing clinical tasks.
HIMSS recommends using the Failure Modes and Effects
Analysis (FMEA), or a topological risk analysis.
The FMEA risk management tool analyzes potential failure
using three criteria: occurrence, severity, and detection.
To measure occurrence, experts must determine the cause of
failures and the frequency with which they are likely to happen. Severity
criteria measures the impact of failures on the end user or the patient, and
detection criteria measures the likelihood that failures will be detected by
the system.
Topological risk analyses allow healthcare organizations to
identify risk elements including single-point failures and common-mode
failures.
“A single‐point failure would be any action by the clinician
that results in harm, injury or death to the patient without a redundant safety
check in place,” clarified HIMSS.
For example, if a provider mistakenly prescribed a drug to
an allergic patient because drug allergy data was not displayed on the ordering
screen, this would be considered a single-point failure.
Meanwhile, a common-mode failure is a safety incident in
which multiple actions by the clinician stem from a single cause.
If a healthcare organization required prescribers to access
multiple screens and memorize patient information to complete prescribing
processes, errors occurring as a result of this ineffective process would be
considered common-mode failures.
“A usability rating process can be developed by adapting
risk assessment methodologies to objectively evaluate the potential for user
error,” states HIMSS. “Certain design factors can lead to user error which
would have patient safety implications.”
One-on-one usability testing can also help to measure
effectiveness. Experts or users can record the number or rate of errors, path
taken to complete a task, severity of errors, and number of requests for help
to measure effectiveness during usability testing.
Naturalness and
consistency
To measure consistency, healthcare organizations can prompt
users to conduct one-on-one usability testing using several key metrics.
Healthcare organizations can measure the time it takes users to achieve expert
performance, the number of icons users remember after completing a task, and
the time spent undertaking manual processes.
Healthcare organizations can also compare difference in
completion time for novice and experienced users to gauge how familiarity with
a system contributes to successful use.
Cognitive load
Measuring cognitive load is a complex process. Healthcare
organizations may need to call upon cognitive psychologists to assist in
administering assessments of cognitive load.
ONC’s Change Package for EHR Usability recommends healthcare
organizations utilize the NASA Task Load Index to assess cognitive workload.
“The NASA Task Load Index (TLX) is a workload assessment
tool that allows users to assess task load or burden based on the mental
demand, physical demand, temporal demand, performance effort, and frustration
of the human,” state ONC officials in the report.
“NASA TLX is widely used as a workload measurement tool
across industries and is available as a printed PDF document or
paper-and-pencil use, or as a mobile application.”.
AHRQ offers healthcare stakeholders a guide on how to use
NASA TLX to measure cognitive load during EHR usability assessments.
User satisfaction
Finally, measuring user satisfaction is imperative for
determining EHR usability. However, user satisfaction ratings are subjective
and should be viewed accordingly.
Healthcare organizations can prompt users to complete tasks
within the EHR and subsequently rate the ease and quality of their experience
according to a point scale.
When researchers from the University of Missouri tested user
satisfaction with different EHR note designs for a 2017 study, they asked
participating clinicians to assign usability ratings to each design template
based on the System Usability Scale (SUS).
SUS is a standard methodology that consists of 10 questions
with five response options per question ranging from “strongly agree” to
“strongly disagree.”
In addition to using SUS, researchers also prompted study
participants to perform one-on-one usability testing with different EHR note
designs.
“We simulated their utility for clinical practice by
imposing time limits and by interrupting one of the tasks with a typical
clinical interruption,” wrote researchers in the study report. “For each
session, we recorded audio, computer-screen activity, eye tracking, and made
field notes.”
Analyzing user performance data alongside SUS user
satisfaction ratings helped researchers determine which EHR note design best
met the needs of clinicians and promoted the highest level of clinical
efficiency.
EHR usability can significantly affect clinical
productivity, provider satisfaction, and patient safety. By observing and
measuring provider interactions with EHR technology, healthcare organizations
can get a sense of how well a technology, workflow, or application fits within
their specific clinical environment.
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