Improving the User Experience for EHRs: How to Begin? After years of seeming neglect, the poor usability of electronic health records (EHRs) is being acknowledged as a critical issue in the U.S. For example, computerized provider order entry, while alleviating transcription errors, facilitated 22 new kinds of medication errors in one facility.1 An evaluation of a major vendor’s electronic medication administration record (eMAR) indicated its potential role in the negative impact on patient safety.2 Due to the large amount of white space on the eMAR, nurses had difficulty seeing lists of medications at a glance and could easily miss giving critical medications. Without an alert, narcotics could be administered and charted multiple times in violation of the ordered timeframe. Medication routes were not linked to specific medications; thus, dopamine could be ordered and charted as being given as a topical medication. Encouragingly, the proposed language for Meaningful Use II includes a section on usability requirements for EHRs. Proactive informaticists may want to start immediately to improve providers’ user experience but be unsure where to begin. This column offers thoughts about how to initiate an organization’s focus on usability. The material is adapted from a publically available HIMSS (Health Informatics Management and Systems Society) whitepaper coauthored by this columnist.3 At least four tactics can help organizations become aware of usability and its importance. Tactics for Launching Usability in Organizations “Wake-Up Calls” Individual Infiltration Methods Finding Internal Champions Using External Experts as a Catalyst ‘Wake-Up Calls Wake-up calls4 are an event, or series of events, significant enough to warrant a change in an organization’s direction. A wake-up call might be inadequate computerized support resulting in incomplete handoffs from the enterprise’s nursing homes to acute care facilities that led to three patient deaths in two weeks. Or continued complaints by clinicians about a product’s usability and their productivity losses could reach the threshold to trigger action. In vendor organizations, the wake-up call might be profit losses to another organization with more usable products. Informaticists can leverage a wake-up call by proposing usability solutions to leaders and measuring the outcomes of those efforts. For example, they can design a usability test with outcome measures (e.g., time, costs, errors) to analyze and redesign an application or portion of a product/device, test users on performance with the redesigned application and compare old and new versions on outcomes. Individual Infiltration Tactics A second tactic is effective but slower. Informaticists could begin by speaking users, user groups, IT teams and managers to learn key usability issues with health IT products. Part of the interviews includes understanding the primary driving factors for the organization and managers (e.g., costs, patient safety, project risks).5 Then, informaticists can leverage that learning by giving evidence from usability product evaluations, estimated return on investment (ROI) and/or communicate ROI from published projects.3 The trick is to relate the studies to the leaders’ or managers’ primary driving forces and interests. Informaticists can compile key usability issues and derive health IT product “pain points.” Pain points are key usability issues with current HIT products. Besides interviewers, informaticists can locate pain points by examining:  Help desk call logs (volume, safety issues)  Lists of system change requests for priority issues, especially patient safety and clinician productivity  Observing users as they use applications to synthesize information (eMARs, clinical summaries, preparing for an encounter with a new patient, getting or giving a handoff, especially for a patient unfamiliar to a nurse or physician)  Working with educators/trainers to find out the “work-arounds” they teach, where users become confused during training or identifying common user mistakes  Working with key stakeholders and having them “think aloud” as they interact with products they find unusable Methods are available for informaticists to ease the transition to incorporating usability into IT projects:  Building a library of usability resources and references  Helping programmers translate user requirements into usable applications  Gathering evidence about the need for usability in current projects5,6  Helping teams understand usability principles and methods and  Keeping a list of usability projects ready for use  Keeping a succinct list of project outcomes for reference and immediate access Relating stories about the impact of usability projects and leveraging successes can be an ongoing, powerful tactic. Informaticists may find they need to communicate successes more than once until managers and leaders understand the impact of usability. Plus, not everyone will embrace usability; gathering allies is important. A powerful tactic is for informaticists to ally with key stakeholders, forming a user voice that is not easily ignored over time. Correlated to usability testing above, informaticists could collect data on a vexing product’s usability to serve as a test case and catalyst for change. For example, Zhang and colleagues7 used heuristic evaluation techniques to discover extensive usability issues with IV infusion pump design. The Toronto Health Network has used these kinds of evaluations to identify critical issues and then work with vendors to create safer healthcare products. Staggers and colleagues evaluated the U.S. military’s ambulatory EHR and found clinicians employed extensive workarounds, had difficulty in obtaining situation awareness of the patient and incurred sub-specialty provider productivity losses due to awkward clinical documentation design.8 Finding Internal Champion(s) Usability efforts in organizations often begin with one manager or analyst who has an interest in usability.9 A manager or analyst working with a supervisor can complete initial projects, gather data about the impacts, and communicate findings to executives. When informaticists have the opportunity to speak with executives, presentations should be data-driven, concise and include specific recommendations. An executive champion for usability can be a key driver for making and sustaining change.4 It is unlikely that usability will be the focus of an executive’s priorities,5 so savvy informaticists will organize communications to correlate with the organization’s mission and priorities. In healthcare, an internal champion may emerge at any level in any division of the organization. Internal champions do not arise as often from the IT department. More typically a clinical champion, CNIO or CMIO recognizes the need and uses wake-up calls to drive change. Nurse informaticists are in a perfect role to be an internal champion for usability efforts no matter which department employs them. External Expert as a Catalyst Organizations may find external usability experts more palatable to start usability efforts.5 Although the consultants can be useful in the short-term, organizations need to have internal stakeholders embrace the principles and precepts of usability for long-term effect. Usability experts are available within and external to health informatics. In summary, these four tactics can be used in isolation or combination to begin improving the user experience in health organizations. The time has come to move beyond poor user experiences with EHRs. References 1. 2. 3. 4. 5. 6. 7. 8. 9. Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. Mar 9 2005;293(10):1197-1203. Guo J, Irdbarren S, Kapsandoy S, Perri S, Staggers N. eMAR User Interfaces: A Call for Ubiquitous Usability Evaluations and Product Redesign. Applied Clinical Informatics. 2011;2(2):202-224 HIMSS. Promoting Usability in Health Organizations: Initial Steps and Progress Toward a Healthcare Usability Maturity Model Chicago, IL: Health Information Management Systems Society;2011. Schaffer E. Instituionalization of Usability: A Step-By-Step Guide. Boston: AddisonWesley; 2004. Rhodes JS. Selling Usability: User Experience Infiltration Tactics. Charleston, S.C.: Rhodes Media; 2009. Carayon P. Human factors in patient safety as an innovation. Appl Ergon. Sep 2010;41(5):657-665. Zhang J, Johnson TR, Patel VL, Paige DL, Kubose T. Using usability heuristics to evaluate patient safety of medical devices. J Biomed Inform. Feb-Apr 2003;36(1-2):2330. Staggers N, Jennings BM, Lasome CE. A usability assessment of AHLTA in ambulatory clinics at a military medical center. Mil Med. Jul 2010;175(7):518-524. Nielsen J, Gilutz S. Usability Return on Investment. Fremont, CA2003.