Electronic Health Record Systems - Usability
1Emergency Department, Royal London Hospital, United Kingdom
When a doctor meets a patient, the assessment will be made in a consistent way. The doctor will take a history, order investigations, make a diagnosis and recommend a treatment plan. This structure is independent of hospital, department or even country. If the doctor arrived at the hospital by car, how they drove the car will have been irrespective of make or model. When they use the IT system at the ED, they will need special training, which will be different for each ED and is likely to be different for each area within the hospital.
IT system usability is the ease with which a practitioner can operate the system they are using. It incorporates three key domains; effectiveness - how complete the task is, efficiency - the energy a user has to expend to complete a task, and satisfaction – the comfort and acceptability of the system to its users. Usability is particularly important in environments which are very dynamic and with high volumes of work.
A characteristic of the IT systems most commonly used in England is that they are classified as Commercial Off-The-Shelf (COTS) products. The advantage to trusts of purchasing COTS products is that they are relatively inexpensive. However, disadvantages include that they are rarely suited to the idiosyncratic requirements of individual departments, and that there is a fundamental disconnect between feedback to the IT vendor and the IT developers, which results in little improvement to systems at the level of the ED.
A system with poor usability can represent a threat to patient safety, for instance in the context of poor interoperability when one system cannot ‘talk to’ another and critical health information is lost. A system with poor usability can also be a contributing factor to unfulfilling work life and consequent burn-out. Conversely a system that is easy to use can contribute to work being meaningful to staff. A system that is easy to use will therefore be both intrinsically more productive, because it will be more effective and more efficient, but also could enable staff to be more productive in tasks not reliant on the IT system, because they are more fulfilled.
To assess usability, one approach is to assess the process of completing identical tasks in different IT systems, for instance ordering an investigation. If there are 15 extra mouse movements or clicks per patient in one system, this may equate to 30 seconds of extra time required by a doctor per patient. The urgent and emergency care system in England treats 25 million patients a year at around £60 per hour. Reducing the time spent per patient by 30 seconds could reduce the cost per patient by £12.5 million, and free up 210,000 hours of clinician time. At a practical level this is the equivalent to adding one doctor per Emergency Department.
Usability assessments include surveys, keystroke level models, and pre/post-implementation models. This review considers the types of usability assessment and the impact of poor usability on users.