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Developing Evidence-Based, User-Centered Design and Implementation Guidelines to Improve Health Information Technology Usability

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Analysis of patient safety event reports showed an association between electronic health record (EHR) usability and patient safety in both adults and children and led to development of an EHR assessment tool that healthcare facilities can use to identify usability and safety issues.

Project Details -
Completed

When designed well and implemented appropriately, health information technology (IT) has the potential to improve the delivery of care. Most current health IT systems, however, are plagued with poor usability and may introduce new patient safety hazards that limit health IT from realizing its full potential. To reach this potential, the technology must be deliberately designed, developed, and implemented with a focus on usability and safe use. This requires vendors to employ a rigorous, user-centered design (UCD) process when developing their product and a well-informed implementation process between the vendor and the adopting organization. To address challenges with health IT usability and safety, researchers at the MedStar Health National Center for Human Factors in Healthcare partnered with Georgetown University and the Institute for Safe Medication Practices. The research team analyzed a large dataset of patient safety event (PSE) reports to identify health IT-related usability and safety issues, developed computational algorithms to assist with characterizing the impact of health IT on patient safety, identified critical health IT usability and safety issues through usability testing, and created a usability and safety assessment tool for use by healthcare facilities.

The specific aims of this research were as follows:

  • Identify health IT-related PSEs from large PSE databases using natural language processing and machine learning techniques in combination with manual review.
  • Systematically categorize the health IT PSEs as either usability design or implementation-related and then identify the specific UCD or implementation process that would have prevented the PSE.
  • Develop, test, and disseminate materials to improve the safety of health IT systems.

The researchers sampled a subset of over one million PSE reports and manually coded more than 5,200 reports as likely or unlikely related to health IT. These coded reports were then used to develop computational algorithms, facilitating identification of patterns and trends. Based on these results, researchers developed an electronic health record (EHR) usability and safety assessment tool and tested it with 10 participants at two healthcare facilities.

Analysis of PSE reports showed an association between EHR usability and patient safety in both adults and children. The tool identified eight usability issues at one site and seven at another, showing promise for its use. While validation of the usability and safety evaluation tool is ongoing, once the testing and optimization of the tool is complete, it will be made available on an open-source site for other organizations to use along with a guide for how to perform the assessment so that it can be self-administered.

Improving Electronic Health Record Usability for Patient Safety

Theme:

Optimizing Care Delivery for Clinicians

Subtheme:

Improving Healthcare Technology Design to Advance Patient Safety

Analysis of patient safety event reports showed an association between electronic health record (EHR) usability and patient safety in both adults and children and led to development of an EHR assessment tool that healthcare facilities can use to identify usability and safety issues.

Poor EHR design and usability hurts patients and burns out providers

While EHRs are used almost universally by hospitals and healthcare facilities across the country, these systems are not usually deliberately designed, developed, and implemented with a focus on usability. Poor design and usability can lead to errors that compromise patient safety and disrupt provider workflow, contributing to increased cognitive burden. Such challenges can lead to provider burnout, resulting in providers leaving the profession. To better understand EHR usability and safety issues, Dr. Raj Ratwani and a team of researchers at MedStar Health’s National Center for Human Factors in Healthcare partnered with computer scientists and clinical experts at Georgetown University and the Institute for Safe Medication Practices to pinpoint digital healthcare-related patient safety gaps in current EHR systems.

Identifying EHR usability issues and potential harm to patients

The research team developed algorithms to identify usability and safety issues from patient safety event reports. Explicit language was identified to associate possible patient harm with an EHR usability issue, in both adults and children. The analysis allowed the team to systematically categorize the EHR-related patient safety events as usability design- or implementation-related issues, and identify the specific user-centered design or implementation process that would have prevented the patient safety event.

“One of the really seminal things that came out of this work is that for the first time, we showed the connection between electronic health record usability and patient safety issues, essentially that patients can be harmed because of the way some of these systems are designed and being used.”
- Dr. Raj Ratwani

Improving EHR usability and safety for any organization

Based on these results, an EHR usability and safety evaluation tool was developed and successfully tested at two healthcare facilities. This tool can be used by any healthcare facility to identify specific issues in its EHR and to identify potential solutions to those issues through usability improvements. The tool includes a guide for how to perform the assessment so that it can be self-administered and disseminated broadly.

This Research is Featured in

Principal Investigator

Ratwani, Raj M.

Organization

MedStar Health Research Institute

Research Profile

Funded Amount

$1,224,973

Research Type

Completed

This Research is Featured in

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Improving EHR Design Increases Patient Safety—Especially for Children

Poor EHR design can harm patients.

Dr. Raj Ratwani and his research team identified pervasive problems with EHR systems that regularly lead to patient safety errors and other issues, regardless of vendor. “If we don’t focus on EHR technology design,” Dr. Ratwani stresses, “it will harm patients.” This issue is particularly true for pediatric patients, who are more vulnerable to EHR usability and safety challenges because of different physical characteristics and developmental issues. For example, lower body weight and less developed immune systems make children less able to tolerate even small errors in medication dosing.

“Poor interface design and poor technology implementations can lead to errors that may result in patient harm, and that is unacceptable and completely fixable.”
- Dr. Raj Ratwani

Dr. Ratwani and team explored how EHR usability can adversely affect safety among pediatric patients, using data from three large academic healthcare institutions. Supported by AHRQ Health IT funding, the team developed algorithms that used NLP to recognize statistical patterns in words used in patient safety reports. This NLP algorithm can identify and code a reported safety event as related or not related to an EHR issue. They found that over a 5-year period, more than one-third of the 9,000 medication-related patient safety reports in the study were related to EHR usability issues, and nearly 20 percent of those may have harmed patients.1 System feedback and visual display problems were the most frequent usability issues, and they most often led to improper medication dosing, putting children at risk. In one case, the EHR did not alert a physician who ordered five times the recommended dosage of a medication for a child, which could be lethal for a child.

Improving EHR design and usability will reduce errors that can lead to patient harm.

In response, Dr. Ratwani says that tools designed to assess functionality of CDS and other EHR functionality can help increase the safety of EHR systems, which will reduce errors that can lead to patient harm. Supporting more stringent policy actions is needed, such as prioritizing safety in regulating EHRs used in documenting the care of children and ensuring that data on system-related harms is collected. An end goal of his work is to establish clear guidelines for both EHR vendors and healthcare provider organizations that will lead to usability improvements and avoid harm to patients.

1 https://www.ncbi.nlm.nih.gov/pubmed/30395517