Abstract
Based on our analysis of descriptions provided by four EHR vendors on their EHR usability efforts, we provide three recommendations aimed at improving the usability of health information technology and reducing clinician burnout. First, EHR vendors need to dedicate increased attention to the design of the entire sociotechnical (work) system, including the EHR technology and its usability as well as the interactions of the technology with other system elements. Second, EHR vendors need to deepen and broaden their understanding of the work of clinicians and care teams by using diverse and mixed method. Third, in collaboration with health care organizations, EHR vendors should engage in cycles of continuous design and learning in order to improve the usability of health IT.
INTRODUCTION
The National Academies’ report on Taking Action Against Clinician Burnout describes the role of health information technology in clinician burnout,1 including some empirical evidence for the impact of poor usability.2,3 The report emphasizes a systems approach to clinician burnout in which the technology (eg, electronic health record [EHR]) is one element of a larger sociotechnical (work) system; such a systems approach is key to improving clinician well-being and patient safety.4 Based on descriptions by four EHR vendors on their EHR usability efforts,5 we highlight 3 themes related to sociotechnical systems approach to clinician burnout and patient safety: (1) the need to design the technology and its multiple interactions with the rest of the work system to support the work of individual clinicians and care teams, (2) the need to understand the actual work of clinicians and care teams, and (3) the need to develop a continuous technology design process.
FROM TECHNOLOGY TO SOCIOTECHNICAL (WORK) SYSTEM
EHR vendors are beginning to incorporate systems approaches in their usability improvement efforts. It was encouraging to read about the explicit citation by vendor B of the SEIPS (Systems Engineering Initiative for Patient Safety) model,5,6 which they use in clinical observations to understand how the software interacts with other system factors, such as organizational policies and teamwork. Other vendors explicitly mention work system elements besides the technology: vendor C described conducting site visits to understand EHR use in the physical environment, while vendor D described the ability to adapt their technology to fit each specific organization. EHR vendors have invested in improving usability of specific EHR functions and their support to clinician tasks such as documentation.
EHR vendors need to adopt a more systematic approach of how health information technology (IT) interacts with other work system elements, and how these interactions affect usability. Workflow integration relies on the EHR technology fitting with each of the work system elements (people, tasks, other tools/technologies, physical environment, organization) and their interactions over time.7 While EHR vendors described methods to enhance EHR usability for tasks performed by individual clinicians, greater focus is needed for designing the EHR to support the patient journey and the work of distributed care teams.8 Shifting the focus from tasks to processes8 includes considering the role of patients in their care journey. Whereas this special issue focuses on clinician burnout, a balanced approach requires attention to usability for all users: healthcare professionals, patients, and caregivers.
FROM WORK-AS-IMAGINED TO WORK-AS-DONE
The EHR vendors use several design approaches, such as user-centered design and design thinking (including the Double Diamond), which emphasize the need to understand the actual work and work system of users and incorporate this knowledge early in the technology development process.5 Usability challenges and even catastrophic technological failures have been linked to the lack of understanding the actual work in the early phase of technology development; this is the difference between work-as-done (actual work or activity) and work-as-imagined (assumed work).9,10 EHR vendors describe various methods for understanding the actual work of clinicians such as direct observation (vendor A), ethnographic methods and contextual inquiry embedded in the Double Diamond framework (vendor B), understanding EHR use in the “natural environment” (vendor C), and consideration for “real-world workflows” (vendor D). A content analysis of the EHR vendors’ statements shows that terms related to user involvement, engagement, and participation were mentioned more than 25 times. The EHR vendors discussed the presence of clinicians as advisors or members of their staff; this provides useful information about clinical work and complements data collection in the actual clinical environment. Several vendors emphasize the diversity of clinicians that they engage with, including leveraging specialty-based user groups, and involving users from a variety of specialties, contexts, geographical locations and level of experience with EHR.
We are encouraged to read about efforts by EHR vendors to build bridges between their technological development activities and the actual work system of technology users. We recommend that these efforts be enhanced by using diverse and mixed methods (eg, process mapping, observation, interview) as early as possible in the development process. To design health IT that is integrated in clinical workflows, a deep understanding of the work system of potential users is needed; EHR vendors should expand the number and types of methods used to ensure the technology supports “work-as-done.”
FROM DESIGN AND IMPLEMENTATION TO CONTINUOUS DESIGN
Usability of health IT is a function of the design of the technology and its configuration by healthcare organizations.11 Enhancing usability requires feedback loops and close collaboration between EHR vendors and their customers (ie, healthcare organizations) and all potential users. The four EHR vendors describe mechanisms to incorporate feedback from clinicians and healthcare organizations postimplementation. The term feedback was mentioned 22 times in 3 of the EHR vendors’ responses, signaling that learning mechanisms exist to assess the usability of technologies and improve their integration in the clinical work system and workflow. EHR vendors need to develop more robust mechanisms for actively seeking feedback on usability. This proactive approach should integrate proactive risk assessment methods to identify potential safety vulnerabilities of new technology functions.
Feedback loops are key to usability improvement and should be structured and institutionalized as organizational learning processes. Designing health IT that meets the needs of diverse users and teams and that supports complex healthcare workflows is a major challenge that requires sustained efforts over time. The distinction between design and implementation or configuration may encourage a separation between the various technology “designers” (eg, software developers employed by an EHR vendor and IT system analysts in a healthcare organization). In order to support deep intraorganizational learning for continuously improving the usability of health IT, EHR vendors (and healthcare organizations) need to create structures and processes for a continuous technology design process.12 This shared responsibility between all relevant partners13 can be enhanced by removing barriers in contractual relationships between EHR vendors and healthcare organizations,14 in order to create a learning healthcare system.15
CONCLUSION
Improving EHR usability in order to reduce clinician burnout should be based on a sociotechnical systems approach that places the technology in a broader work system, emphasizes the actual work of clinicians and care teams, and promotes a continuous design process and learning at all levels, including EHR vendors. We need to encourage learning opportunities and interactions between EHR vendors and the health informatics research community in multidisciplinary efforts, such as this special issue.
FUNDING
This publication was partially supported by the Clinical and Translational Science Award program, through the National Institutes of Health National Center for Advancing Translational Sciences (grant UL1TR002373) and the National Library of Medicine Institutional Training Program in Biomedical Informatics and Data Science through the National Institutes of Health (grant T15LM007450-19). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
AUTHOR CONTRIBUTIONS
PC and MES contributed to the conception and design as well as the initial draft and the critical revision of the manuscript. PC takes responsibility for all aspects of the work.
DATA AVAILABILITY STATEMENT
There are no new data associated with this article.
CONFLICT OF INTEREST STATEMENT
The authors have no competing interests to declare.
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Associated Data
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Data Availability Statement
There are no new data associated with this article.