Usability and Information design for Electronic he

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Usability and Information design for Electronic health record systems: Improving EHRusability with the help of information systemsThis project will focus on the health information technology (HIT) intervention for theimprovement of electronic health record (EHR) usability.OverviewThe Healthcare Information and Management Systems Society (HIMSS) definedusability as the effectiveness, efficiency and satisfaction with which specific users can achieve aspecific set of tasks in a particular environment (himss.org, 2019). From this statement,clinicians, physicians and end-users of EHR needs to be efficient and effective using EHR.Efficiency is the speed at which users can complete the tasks while effectiveness is the accuracyand completeness of the tasks at hand. While keeping these two terms in mind, the goals of thisproject is using HIT intervention to assess and improve EHR usability among its users therebyproviding a meaningful use of the systems. As described by pewtrust.org, poor usability of EHRcan lead to many errors, unforeseen safety risks, and other serious mistakes, which may lead tounintended consequences for the clinician as well as for the patient (pewtrust.org, 2019). It isimportant to note that use of EHRs in physician practices and in healthcare organizations directlyimpacts the communication and management of laboratory information in patient care,particularly reporting of laboratory results and test order management. However, as reported byGlaser, EHRs were the fourth most common cause of burnout EHR complaints beat outinsurance issues, threat of malpractice suits, concerns about salary, and patient volume (Glaser,2017).In addition, errors from poor EHR usability can be of a great impact especially if itinvolves medications and delayed treatments.InterventionIn addressing this challenge, one has to encourage usability by the improvement of theorganization's EHR's user interface (UI) designs. There are gaps between current and futureimproved EHR systems designs that could have resulted from insufficient incorporation of theUI designs within several networks. Per Risvi et.al, despite the high EHR adoption rates,substantial gaps exist between the current state of EHRs and their potential usefulness. Recently,the HIT end-user community and EHR experts have pointed specifically to the cognitivechallenges resulting from poor EHR usability as one of the key reasons for this gap. Also,

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substantial level of disparity exists around perception of HIT usage and its possible outcomesamong its various users, having wide range of technology skills further confound the situation(Rizvi et. al, 2017). Usability has been defined in various ways and typically encompasses a setof evaluation methods to understand user experiences for the purpose of creating more desirable,usable, and useful products. .Many factors can affect slow usability of EHRs are usercharacteristics, workloads associated with progress notes typing, repeated task performance, andother subjective system assessments. There are nine principles, as reported by HIMSS, for aneffective and efficient EHR usability. These nine principles will be used in alignment with ourproposed HIT intervention. The ultimate goal will be for the enhancement of visual display, UIdeisgn aspect, and other IT related features for the improvement of EHR usability. For thispurpose, Genex Hospital EHR system will be the testing candidate.1. SimplicityMost physicians are used to writing clinical notes in seconds, but spending time to enterthese information into the EHR system may seem as a heavy task thereby reducing usability. Thefirst step is incorporating a simple user interface designs into Genex EHR system, such as anestablishment of interactive patterns for the physician to document findings into the EHR. Anexample of such design is a software, Story Engine, an application tool used to build and presentstories. The design consist of two parts, Story builder and Story Presenter. Per hhs.gov, StoryBuilder is a collaborative tool; it allows user/authors to design edit and/or view each other'swork while also allowing authors to work independently. Story Presenter is the Graphical UserInterface (GUI) downloaded during Story Engine installation that allows patients to view storiescreated by Story Builder (healthit.gov, 2013). The design will enable physicians to create theirentries into the system and the patient can also view the records easily. In addition, this toolcontains other visual aids such as highlights, bolds, and underlining of important information, anapproach that will present a clean, clutter-free screen for the users.2. NaturalnessIn an effort to develop a common user guide interface style guide for users, well-knownterms that are common to the workplace will be deployed into the UI system. Common featuresof information sources within healthcare such as clinical workflows, balances and checks forcertain diagnoses, pathology, cardiology, laboratory related procedures etc. creates a naturalEHR UI that are specific to the needs of the physicians. These set of common elements within

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the UI system will reduce the burden of frustrating searches of the end-users, and leadingtowards better user interaction with the system. In addition, the UI system will contain a patternof designs that allows navigation, searching from known database, and other tools such asslideshows, abstracts, scientific knowledge database, and other aspects of healthcare thatestablishes casual and formal impression for the end-users. This characteristic of the system willengage more clinicians with the EHR system.3. ConsistencyAs stated by himss.org, consistent EHR interfaces promote continuity and reduceconfusion for providers (himss.org, 2019). A consistent EHR UI ensures that all parts of thesystem have the same look and feel, thereby enabling physicians to navigate seamlessly throughthe different workflows. For example, Henry stated an inconsistency in data entry, a clinician'swork process may make it hard or impossible to appropriately enter the desired EHR data. Onecase researchers analyzed showed that a clinician chose the wrong frequency for a drug to beadministered because the clinician didn't realize that the order in which the options werepopulated into the EHR had changed (Henry, 2018). To reduce inconsistencies, certainterminologies and data entry fields compatible with the UI will be applied in the proposed UIprogram. Consistency helps to reduce the learning time for the new proposed project as end usersget familiar with the given experience of using the current system. In an attempt to keep a usableand user-friendly design that always provide a consistent experience, the UI design will beimproved for Genex hospital EHR system while keeping the same terminologies and data entryfields.4. Forgiveness and FeedbackHIMSS simply defined this principle as "If you make a mistake, the application helps youavoid it or the application provides a method to recover from errors gracefully (the system is"forgiving"). The system provides informative feedback to the user about actions they are aboutto take or have taken (himss.org, 2019). There are situations where errors can occur and having aUI that allows checks and allows for correction of these errors is crucial for an effective UI.There will be an in-built checklist in the Genex improved UI design where using administrativemethods such as the use of a common access card allocated to each end-user will be used toaccess the system. Using this encrypted card, one can track and identify errors and the systemwill also allow for corrections with digital signatures for verification and validity. The system

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will ask the end-user for confirmation, in any event of a suspected error, before allowing theaction. It will be a system that allows for undo and redo of actions within the UI design.Prior to incorporating this feature into Genex EHR system, an informal usability testingwill be conducted with selected end-users. These selected users will include a range of clinicaland administrative Genex staff in order to gather, select, and interpret the "forgiveness andfeedback" feature that will be installed into the UI design. All users will be encouraged to test inits early design and evaluate the ease of learning, effectiveness, and assess for both qualitativeand quantitative satisfaction.5. Effective Use of LanguageOverall, language with an effective EHR UI should read like natural English. Using theHIT intervention tool, while focusing on the physicians in a healthcare setting, effective use oflanguage will answer following questions:Can the physician easily find and place orders and view results for tests?Is it easy for the end-user to conduct and complete a patient visit while adhering to allregulatory requirements?Are the 'human elements' applied when dealing with a patient, and not engaged with thescreen throughout the patient visit?Keeping all of these questions while designing the UI will help reduce misunderstanding andincrease usability of the EHR systems. The goal of this feature in the propsed UI design is toreduce memory load. The data presented will be simple, brief, consolidated, and summarizedand will not require the end-user to recall, but rather recognize.6. Efficient InteractionAn efficient EHR usability is also closely tied to EHR interoperability. When an EHRsystem cannot transmit health data with another system, it becomes less usable because itlimits how providers can use it to coordinate care. In our intervention, the Genex EHRsystem will be designed to allow for efficient health data exchange between patients,physicians, health providers and other associated departments within Genex. This improvedUI design will cater to the 'meaningful use' as mandated by the HITECH Act. This newsystem will be designed to allow the following features, as described by Henricks forefficient interoperability: Computerized provider order entry (CPOE), e-prescribing (eRx),report ambulatory Clinical Quality Measures to CMS/States, implement one clinical decision

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support rale ,provide patients with an electronic copy of their health information, uponrequest, provide clinical summaries for patients for each office visit, Drug-drug and drug-allergy interaction checks, record demographics, maintain an up to date problem list ofcurrent and active diagnoses, maintain active medication list, maintain active medicationallergy list, record and chart changes in vital signs, record smoking status for patients 13years or older, capability to exchange key clinical information among providers of care andpatient-authorized entities electronically, and protect electronic health information(Henricks, 2011). Also, a feature to send reminders to patients and physicians for follow upvisits.7. Efficient Information presentationWith the complexity of EHR systems, where attempting to visually display one'snonlinear work of patient care can be challenging. The goal of the HIT intervention will be toprovide several ways to utilize, navigate, and find desired content on Genex EHR system. Toachieve this aim, the improved UI design will include tag pages that feature popular keywordsused in entries. Within these entries, there will be an extra feature that can split up the entriesinto several major categories that are beneficial to the end users. Some of the incorporatedcategories will include demographics, progress notes, medical histories, radiology and laboratoryreports, medications etc. These proposed tags will be color-coded, as stated by St. John, usingcolor coding in the EHR is meaningful to how a clinician perceives and reacts to the informationpresented (St. John, 2015). The newly designed UI interface will have colors as red for issuesthat are considered ’hot, danger, extreme warning, emergency alarm', yellow for 'caution,requires attention moderate alert', green for 'safe, normal, proceed'; and in rare cases, blue for'cold, advisory. The main goal for this feature in the project is to alleviate the appropriate densityof data and allow easy readability through the meaningful use of colors within the UI design.8. Preservation of ContextThe reduction of unnecessary screen changes, visual interruptions, pop-ups, instructions,IT related functions, and other screen repairs within Genex system will be the main goal for thistask. As reported by St. John, alerts are designed to inform (users) of possible patient safetyissues, but their frequency and often lack of necessity make them the electronic equivalent of theboy who cried wolf." The intention of an alert is to protect the patient, but too often, we are notcareful and consistent about how we design, deploy, and monitor the alerts (St. John, 2015). The

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