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3 User-Centered Design Practices to Drive EHR Usability, Optimization

Employing user-centered design practices can help healthcare organizations pinpoint clinical workflow challenges to improve EHR usability.

Digital health transformation has led to widespread EHR adoption, with 96 percent of hospitals using the technology. However, clinician satisfaction with EHR usability is anything but common.

EHR usability is "the effectiveness, efficiency, and satisfaction with which specific users can achieve a specific set of tasks in a particular environment," as defined by the Healthcare Information and Management Systems Society (HIMSS).

Two recent studies measured EHR usability using the System Usability Scale (SUS), a standard methodology that consists of 10 questions. One study found that physicians' average EHR usability score was 46 out of 100, and a separate study revealed that nurses' average score was 58 out of 100, both failing grades.

Improving EHR usability is critical, as low EHR satisfaction is linked to clinician burnout and a higher likelihood that a clinician will leave a healthcare organization. What's more, poor EHR usability puts patient safety at risk. A 2023 study published in JAMA Network Open found that frontline EHR user experiences of usability are directly associated with hospitals' EHR safety performance.

As healthcare organizations look toward EHR optimization, employing user-centered design (UCD) principles can go a long way. UCD is an iterative process in which the end-user influences the design throughout the development, implementation, and validation of a product or workflow, according to HIMMS.

Below, EHRIntelligence highlights three UCD techniques healthcare organizations can employ to drive EHR optimization.

EHR Audit Log Analysis

Practices can leverage EHR audit log data to understand workflow pain points better and inform EHR optimization projects.

EHR audit logs are automated tracking features that monitor clinician activity within the EHR. Specifically, the automated tool can track the time clinicians spend documenting and carrying out certain tasks, such as chart review and messaging. EHRs certified by ONC must be able to generate audit log data based on a set of specific events to create comprehensive reports of clinicians' EHR use.

A 2020 study leveraged EHR audit log data from an integrated healthcare delivery system to better understand how physicians use the EHR search feature.

The researchers found that although the search feature was a key tool for efficiently retrieving EHR data, providers also used the search feature in ways that revealed "forced inefficiencies of poor EHR design."

For instance, pharmacists' searches for terms such as "decrease" and "discontinue" underscored limitations in understanding medication changes over time. The study authors suggested a timeline display of medication orders, administrations, and refills could help improve pharmacists' workflows by compiling patients' medication history.

Audit log data also highlighted challenges in developing a comprehensive clinical picture from siloed EHR data.

For example, providers searched "aspirin" with terms such as "statin," "catheterization," "metformin," and "pradaxa." The authors suggested developers could combine these terms within a cardiometabolic disease and treatment pathway to improve EHR usability.

Site-Specific EHR Usability Testing

ONC requires usability testing as part of its EHR certification program. However, EHR developers conduct usability testing in a laboratory setting. There are no post-certification processes required to ensure EHR platforms perform as anticipated in practice settings.

Healthcare organizations often customize EHR implementations, which can introduce usability issues. For example, providers may feel that EHR systems should be modified to individual workflow preferences, resulting in pressure on the organization to customize workflows.

The difference between the usability of a system in certification testing and post-implementation encountered by the end-user is known as the "EHR usability reality gap." This gap persists, in part, because healthcare organizations often do not have the resources to hire usability experts to assist with site-specific EHR optimization.

A recent study published in Applied Clinical Informatics illustrates a "discount" approach for site-specific EHR usability testing that could help healthcare organizations drive EHR optimization without enlisting the help of experts.

Researchers at an academic health center developed a site-specific EHR usability program to evaluate new features available in the EHR across three user test events. Each event contained up to six end-users who measured the features for user efficiency, effectiveness, and satisfaction.

The team identified 33 usability concerns (2.5 problems for each feature tested). More than 70 percent of the usability concerns were correctable.

For instance, the user test event revealed that the original clinical pathway to guide users toward the most appropriate vascular access method did not account for alternative workflows.

"Complete redesign of this feature likely prevented a large number of unfortunate user experiences," the study authors noted.

Card Sorting Evaluation

Constantly redesigning and testing the EHR to ensure it supports end-user needs is essential to the iterative user-centered design process.

A 2020 study outlines a process known as card sorting as an effective, inexpensive tool that can help drive EHR usability. The goal of the process is to reveal end-user expectations about how to organize content within the EHR.

The process begins with a healthcare organization identifying a list of 20 to 30 relevant topics related to its practice.

Then, participants group topics together into categories. Participant consensus about categories provides researchers with information about which items should be grouped, which can inform EHR optimization.

Reverse card sort (also known as "tree testing") is a technique used to evaluate the ease with which end-users find content within a software's information architecture. The "tree" is the site structure of the EHR, which is essentially a simplified structure of the software. Tree testing allows end-users to evaluate the EHR structure in isolation without factors such as visual design or navigation aids.

End-users are provided with tasks and asked to complete them by navigating a collection of cards (each with a category from the initial card sort). This approach helps researchers evaluate whether a predetermined hierarchy is a good way to find information.

The study authors pointed out that while card sort and reverse card sort methodologies have benefits, they also have limitations.

"Firstly, this type of study is performed outside the actual EHR system and is stripped from its context," the researchers explained. "One is able to obtain information about how individuals combine concepts. However, this does not provide information on how effectively users will find relevant information in the final EHR system."

Additionally, it is challenging to determine how the wording of topics may impact the way end-users group cards. To offset this limitation, researchers should instruct participants to think of underlying concepts beyond the words provided.

As healthcare organizations work to improve EHR usability, it is important to keep in mind that user-centered design is an iterative process. With increasing amounts of health data at clinicians' fingertips as the digital health transformation progresses, promoting EHR usability is something that healthcare organizations must prioritize.

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