Usability Engineering for EHR Implementation
Ross Speir, Human Factors Engineering, Office of Health Informatics
For the past several years, VA investment in improving the usability of its health IT (HIT) systems has led to the maturation of a usability engineering competency. Usability engineers engage with project teams across the IT development lifecycle to help articulate user needs, create realistic scenarios of intended use, and evaluate the usability of software designs. Over time, usability engineering methods and tools have been honed to better uncover design problems that would impede the effective, efficient, and safe use of software. Furthermore, a growing portion of the VA clinician community routinely volunteers lunch-time to support usability efforts that advance our shared goal to improve VA HIT system usability.
This article will discuss how the VA usability engineering competency could be leveraged to reduce costs of an EHR implementation at sites and expedite users becoming effective and efficient within the new system.
At some point in time, someone at a medical center will flick a switch that turns on a new, modernized EHR system. With appropriate planning, preparation, and training, this new system will support clinicians with the important work of providing patient care.
Yet making changes to a dynamic, complex system — such as a health care delivery system — will introduce unintended consequences. And this particular change involves integrating a sophisticated software product into a safety-critical environment and implementing new workflows that enable various user roles to collaboratively carry out interdependent tasks intended to achieve goals that are often uncertain and dynamic. This change process undoubtedly will have a cascading effect that impacts the ability of end users to carry out work efficiently and effectively.
The VA usability engineering competency, established to uncover barriers to user efficiency and effectiveness during software development, can also be leveraged to mitigate barriers and risks during HIT implementation.
Throughout a software development project, usability engineers will work with both stakeholders and users to create contextually-based scenarios that represent real-world situations that the new system must accommodate. These scenarios describe common situations, as well as situations reflecting complex work (‘edge cases’), that will occur less frequently. Sometimes, scenarios will be created to intentionally introduce user error (as an assessment of error-tolerance). Scenarios are then given to intended users to walk through the software (following one of several usability assessment protocols) in order to uncover potential problems.
This type of scenario-based assessment might also be applied to HIT implementation — if the organization changes how it typically thinks about ‘usability.’ When evaluating usability during software development, the ‘usability’ is typically an attribute of the user interface design — a quality measure that indicates a goodness of fit for users, tasks, and environment. The solutions to problems that are uncovered typically lead to changes in the design of the software’s user interface.
Utilizing a scenario-based assessment for a HIT implementation effort, the organization would need to think about ‘usability’ as an attribute of the integrated system — the technology, the clinical workflow, information flow across systems, user communication, etc. Potential problems uncovered as part of a ‘system usability’ assessment — carried out as part of deployment — would be addressed by more immediate solutions (changing software configurations, modifying workflows, updating user training, etc.). But the overall objective of the usability engineer remains the same — to determine if specified users can achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use.
To prepare for the transition to a modernized EHR, Human Factors Engineering (HFE) has begun partnering with front-line health care providers to develop high-value, end-to-end scenarios of patient care across multiple clinical services. The focus is on the needs and goals of the users; not on the specific technology. These scenarios will be publicly available to program offices, subject matter experts and implementation teams at local sites. These scenarios can be used to:
- Mitigate risks of unintended consequences associated with deployment through context-relevant testing of system usability, interoperability, data quality, and patient safety;
- Walkthrough local EHR configurations and workflow implementations from a perspective of cross-service care continuity;
- Expedite adoption of EHR and workflows by supplementing user training with VA-centric patient care scenarios considered high-value by front-line providers.