Human Factors Quarterly / Winter 2018 / Issue 21

Ensuring Electronic Health Record (EHR) Systems Work for Clinicians: A Resource for Assessing System Usability

Craig Harrington, MS, MSSW, VA Digital Services, and Ross Speir, Human Factors Engineering (HFE), Office of Health Informatics (OHI)

The Department of Veterans Affairs (VA) is expected to embark on a bold journey to implement and deploy a commercial off-the-shelf (COTS) product as the primary software system supporting Veteran Health Administration (VHA) clinicians in the care of their Veteran patients. This decision has been applauded by Congress and other government leaders for its potential to benefit clinical users and subsequently Veterans being cared for by VHA clinicians.

However, this effort is not without risks. Several factors cloud the future of this effort. These factors include: High cost; the scope, which includes more than 170 medical centers and over a thousand clinics; the transition from the Veterans Information Systems and Technology Infrastructure, known as VistA, a well-established but aging EHR; a timeline that is expected to extend 10 years into the future; and the underlying challenge of an enterprise-wide EHR for the nation’s largest integrated health care system. EHRs represent the confluence of a multitude of knowledge domains – at the highest levels there is business management, operations, communication, information science, human resource management, computer science and related technologies, medicine, nursing, pharmacy, and a host of ancillary health care professions. To achieve the best outcomes for Veterans, these complex and demanding fields must be tightly coordinated. As if this is not enough of a challenge, VA leaders must recognize that new developments in these fields (like genomics and precision medicine) are occurring almost daily.

Clinical informatics and human factors engineering are both disciplines that focus on bridging technology and health care. A central tenet is to apply knowledge enabling VHA to reduce the cognitive burdens on clinical users that in turn leads to improving the effectiveness and efficiency of health care delivery. The goal is to create systems that are like good power tools – they are satisfying, not frustrating or irritating to use. They make clinicians more productive and better at their job of caring for Veterans.

Usability is a concept that recognizes the goodness of a system that relies not just on its technical features and capabilities, but the degree to which the system enhances the skills of users, minimizes the opportunities for errors and slips, and contributes to improved outcomes through the way that information flows through a system and how it is presented to users. Poor usability is a major barrier to clinician adoption of an EHR as it forces clinicians to rely on their memory when stressful situations can be life-or-death; to keep information and perform calculations in their heads; to struggle to remember where things are in the system; to flip back and forth between screens for related information; and in some particularly bad cases, to rely on paper notes. 

A system with excellent usability is cherished by its users, as it allows them to focus on their goal of making patients healthier. Information is presented in a way that mimics how they think and practice. Information is presented clearly so clinicians are not required to search for it. Usability strengthens decision-making, guiding clinicians, making judicious use of reminders and notifications to prevent timely events from being neglected. These are just some of the considerations in an evaluation of system usability, but they convey the need for clinicians to have a highly usable EHR to provide high-quality patient care.

The promise of better health care outcomes for Veteran patients can be achieved only if the components of a deployed EHR system, e.g. the hardware, the many software applications, the clinical data, and the clinical workflow, integrate seamlessly for clinicians, enabling them to accomplish their work effectively, efficiently, and safely. Towards this end, Human Factors Engineering (HFE) is working with front-line clinicians to develop clinical scenarios that describe, from the users’ perspectives, how an EHR system could support user goals in specific patient care situations. These scenarios serve as descriptive models of the most common, and the more complicated, aspects of providing patient care. Creating a library of scenarios will enable clinical informaticists to select high-value patient scenarios for their site, and use them to uncover potential usability problems during workflow modeling, technology implementation, or system testing.

As an example, a possible scenario details how a 68-year-old Veteran with several chronic health problems is brought to the emergency room of a VA medical center by a police officer after the Veteran was discovered standing on the railing of bridge, contemplating suicide. The scenario would detail how the various participants in this realistic but imagined situation would interact among each other and with the EHR in order to identify the patient’s issues and bring about the best solution for the Veteran in crisis.

The value of a scenario is that it establishes a clinical problem in a context that users understand, instead of focusing on the technical features or capabilities of an EHR. Scenarios are designed to be technology-agnostic; they are abstract descriptions of realistic problems that can then be played out using an actual EHR. A well-crafted scenario enables an assessment to be conducted with understanding how the EHR supports and complements the clinicians in providing care. A scenario serves as a valuable tool to assess if the EHR, with its attendant workflows, is designed in a way to support user needs for achieving goals of care, in terms of both micro and macro interactions with the system.

An initial set of scenarios can be found in the Scenario Library of the User Experience Guide for VA Health IT Systems (the UX Guide). The next edition of the Human Factors Quarterly newsletter will provide guidelines and tools for creating a patient care scenario.