Optimizing the Electronic Health Record for Cardiac Care

As electronic health records (EHRs) have been implemented at health care delivery sites, clinicians have found that they have increased documentation time and reduced time with patients. As such, these implementations have negatively impacted clinical workflow and have been cited as a significant cause of clinician burnout. This research studied the usability of EHRs, as used by cardiac care physicians and nurses, to inform a framework for clinician-centered design for EHRs that was validated with a fully functional EHR prototype. Recognizing the importance of patients on the healthcare team, the researchers also created a personal health record (PHR) prototype for patients and evaluated its usability as well.

A mixed methods study was undertaken involving four academic and four private practice settings. The focus on cardiac care was chosen because of its broad reach across a healthcare enterprise: management of cardiovascular disease crosses outpatient and inpatient care and involves numerous specialties including cardiologists, primary care providers, emergency room physicians, cardiac care nurses, catheterization lab nurses, and technicians.

The specific aims of the research were as follows:

• Determine the usability of the EHR as measured by provider-defined usability. 
• Use value-based software engineering principles and agile development methods to link providers with clinical content and human-computer interface expertise to build and test wireframe models of desired EHR functionality. 
• Use information obtained through the first two aims to synthesize the characteristics of users’ preferences and demographics and propose a set of best practice designs to guide EHR developers. 

To evaluate clinicians' wants, needs, and barriers to using their current EHRs, simulated patients were used to present complex clinical case scenarios to clinicians, who documented those scenarios in their own EHRs. Clinicians rated their installed EHR design as ‘poor,’ and their satisfaction with it as ‘neutral.’ For patients' wants, needs, and barriers to using a PHR, patients used their own clinical scenarios. Out of the resulting evaluations, the researchers created design requirements for an optimized EHR that supports workflow, information flow, and decision support needs of the cardiac care team. The planned wireframes for testing proved insufficient for clinicians to react to and, thus, the researchers instead built a web-enabled functioning prototype EHR that focused not on documents but instead on data presentation and aggregation.

Using two high-resolution monitor screens, the predominant function of the left screen was for review and validation of data, while the right was primarily for documentation. This format allowed clinicians to keep key data available for review and reference as documentation was completed, without needing to open and close applications, thus reducing cognitive load. Clinicians ranked the prototype at the upper range of ‘good’ bordering on ‘excellent.’ The PHR evaluation revealed greater acceptance by younger patients, and that adoption was related to computer self-efficacy but not demographics, health literacy, medication adherence measures, or patient activation. Included in the evaluation was eye-tracking to measure cognitive load, which allowed the researchers to alter their PHR design to reduce patient cognitive load.

The researchers concluded that including end users in design considerations leads to significant improvements in usability. The prototypes created during the research can be used by vendors to understand desired functionality more robustly.