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Usability and Information design for Electronic Health Record Systems:Improving EHR usability 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) defined usability as theeffectiveness, efficiency and satisfaction with which specific users can achieve a specific set oftasks in a particular environment (himss.org, 2019). From this statement, clinicians, physicians andend-users of EHR needs to be efficient and effective using EHR. Efficiency is the speed at whichusers can complete the tasks while effectiveness is the accuracy and completeness of the tasks athand. While keeping these two terms in mind, the goals of this project is using HIT intervention toassess and improve EHR usability among its users thereby providing a meaningful use of thesystems. As described by pewtrust.org, poor usability of EHR can lead to many errors, unforeseensafety risks, and other serious mistakes, which may lead to unintended consequences for theclinician as well as for the patient (pewtrust.org, 2019). It is important to note that use of EHRs inphysician practices and in healthcare organizations directly impacts the communication andmanagement of laboratory information in patient care, particularly reporting of laboratory resultsand test order management. However, as reported by Glaser, EHRs were the fourth most commoncause of burnout EHR complaints beat out insurance issues, threat of malpractice suits, concernsabout salary, and patient volume (Glaser, 2017). In addition, errors from poor EHR usability can beof a great impact especially if it involves 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 the UIdesigns within several networks. Per Risvi et.al, despite the high EHR adoption rates, substantialgaps 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 cognitive challenges resultingfrom poor EHR usability as one of the key reasons for this gap. Also, substantial level of disparityexists around perception of HIT usage and its possible outcomes among its various users, having awide range of technology skills further confound the situation (Rizvi et. al, 2017). Usability hasbeen defined in various ways and typically encompasses a set of evaluation methods to understanduser experiences for the purpose of creating more desirable, usable, and useful products. Manyfactors can affect slow usability of EHRs are user characteristics, workloads associated withprogress notes typing, repeated task performance, and other subjective system assessments. Thereare nine principles, as reported by HIMSS, for an effective and efficient EHR usability. These nine

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principles will be used in alignment with our proposed HIT intervention. The ultimate goal will befor the enhancement of visual display, UI design aspect, and other IT related features for theimprovement of EHR usability. For this purpose, Genex Hospital EHR system will be the testingcandidate.1.SimplicityMost physicians are used to writing clinical notes in seconds but spending time to enter thisinformation into the EHR system may seem as a heavy task thereby reducing usability. The firststep 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 a design is a software, Story Engine, an application tool used to build and presentstories. The design consists 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's workwhile also allowing authors to work independently. Story Presenter is the Graphical User Interface(GUI) downloaded during Story Engine installation that allows patients to view stories created byStory Builder (healthit.gov, 2013). The design will enable physicians to create their entries into thesystem and the patient can also view the records easily. In addition, this tool contains other visualaids such as highlights, bolds, and underlining of important information, an approach that willpresent a clean, clutter-free screen for the users.2.NaturalnessIn an effort to develop a common user guide interface style guide for users, well-known termsthat are common to the workplace will be deployed into the UI system. Common features ofinformation sources within healthcare such as clinical workflows, balances and checks for certaindiagnoses, pathology, cardiology, laboratory related procedures etc. creates a natural EHR UI thatare specific to the needs of the physicians. These set of common elements within the UI system willreduce the burden of frustrating searches of the end-users and leading towards better userinteraction with the system. In addition, the UI system will contain a pattern of designs that allowsnavigation, searching from known database, and other tools such as slideshows, abstracts,scientific knowledge database, and other aspects of healthcare that establishes casual and formalimpression for the end-users. This characteristic of the system will engage more clinicians with theEHR system.3.ConsistencyAs stated by himss.org, consistent EHR interfaces promote continuity and reduce confusionfor providers (himss.org, 2019). A consistent EHR UI ensures that all parts of the system have thesame look and feel, thereby enabling physicians to navigate seamlessly through the differentworkflows. For example, Henry stated an inconsistency in data entry, a clinician's work process

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may make it hard or impossible to appropriately enter the desired EHR data. One case researcheranalyzed showed that a clinician chose the wrong frequency for a drug to be administered becausethe clinician didn't realize that the order in which the options were populated into the EHR hadchanged (Henry, 2018). To reduce inconsistencies, certain terminologies and data entry fieldscompatible with the U1will be applied in the proposed UI program. Consistency helps to reduce thelearning time for the new proposed project as end users get familiar with the given experience ofusing the current system. In an attempt to keep a usable and user-friendly design that alwaysprovide a consistent experience, the UI design will be improved for Genex hospital EHR systemwhile keeping the same terminologies and data entry fields.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 about totake or have taken (himss.org, 2019). There are situations where errors can occur and having a UIthat allows checks and allows for correction of these errors is crucial for an effective UI. There willbe an in-built checklist in the Genex improved UI design where using administrative methods suchas the use of a common access card allocated to each end-user will be used to access the system.Using this encrypted card, one can track and identify errors and the system will also allow forcorrections with digital signatures for verification and validity. The system will ask the end-userfor confirmation, in any event of a suspected error, before allowing the action. It will be a systemthat allows for undo and redo of actions within the UI design.Prior to incorporating this feature into Genex EHR system, an informal usability testing will beconducted with selected end-users. These selected users will include a range of clinical andadministrative Genex staff in order to gather, select, and interpret the "forgiveness and feedback"feature that will be installed into the UI design. All users will be encouraged to test in its earlydesign and evaluate the ease of learning, effectiveness, and assess for both qualitative andquantitative 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 the 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?

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