Astute readers (for the record, I assume all my readers are astute, thank you very much!) will surely know that I’ve been writing and talking about human-centered design and its application to healthcare for a while now. Even more astute (astuter?) readers will know that my colleague, Jerome Pagani, PhD, and I recently published a book titled Designing for Health: The Human-Centered Approach (which can be pre-ordered here for those interested). I am focused on making healthcare work for humans because it really matters. How so? Let’s look at a recently published study.
In a JAMA article that was released last week, researchers wanted to learn “… whether [electronic health record] safety performance is associated with EHR frontline user experience in a national sample of hospitals.” The question comes about because while we have improved some aspects of patient safety, we haven’t eliminated problems such as medication ordering mistakes despite most U.S. hospitals having sophisticated technology like electronic health records (EHR). The researchers hypothesized that poor EHR usability might be one cause of this patient safety deficit.
How does usability relate to human-centered design? The authors note that “EHR usability can be defined as the effectiveness, efficiency, and satisfaction with which specified users achieve specified goals in particular environments.” The key to good usability is to leverage the knowledge of how we think and process information to make it easy to achieve our goals. In other words, usable systems, technology, or workflows employ human-centered design as a core part of their build.
The scientists compared two large databases to help draw their conclusions. To assess the usability of various EHR systems, they looked at data from KLAS Research’s Arch Collaborative. The collaborative consists of several hundred healthcare organizations that survey their clinicians regarding technology experience using standardized instruments so they can compare results. To examine patient safety, the researchers used the National Quality Forum Leapfrog computerized provider order entry (CPOE) and EHR safety test. Leapfrog is a voluntary survey wherein U.S. hospitals simulate what happens in their test EHR systems when doctors order specific medications for “patients” who have medical concerns such as drug allergies, health problems, or polypharmacy.
The authors looked for hospitals that were both members of the Arch Collaborative and had taken the Leapfrog test. After excluding groups with incomplete data, they found 112 hospitals with 5,689 physicians who scored their hospital’s EHR usability. The hospitals were widely distributed across the U.S. and were principally non-profit and non-teaching.
What conclusions could the researchers draw? They found that “[t]here was a significant association between the safety of the operational EHR and the experience that frontline clinicians have in using it, probably related in part to the frustration that they experience with medication ordering in poorly designed EHRs. For example, poorly designed EHR medication ordering may involve too many clicks and too many alerts that would not only frustrate physicians but also cause them to ignore the alerts.” As we know, correlation does not indicate causation. Hence, we can’t prove that poor usability directly led to decreased patient safety, yet … it likely does.
As the scientists point out, and as precious few physicians understand, most modern EHRs are highly configurable by the hospital or healthcare system implementing them. As I like to say, once you’ve seen one “Vendor A” EHR implementation, you’ve seen one “Vendor A” EHR implementation. It’s certainly possible for a doctor who is a great user of a specific company’s EHR to go across the street to a hospital using the same company’s EHR and struggle to get their work done. I know it doesn’t seem possible, but it is. Therefore, for highly configurable EHRs, it is nearly impossible to solely “blame” the vendor for their usability score. That doesn’t stop us, though!
The authors of this study conclude that “[b]oth health systems and vendors need to consider usability not only as critical for the frontline users, but also as a critical safety issue in the design, development, implementation, and maintenance of these complex EHR systems, and they should work together with frontline users and organizations to improve usability without compromising the integrity of safety performance.” I concur and add the stipulation that usability will improve in direct correlation with the application and use of human-centered design as these technologies and associated workflows are rolled out in hospitals, clinics, and even patients’ homes around the world.