Making health IT “usable” on the Frontlines


Usability of health information technology (health IT) systems means many things to many people.  If we look at the industry-standard International Organization for Standardization definition, usability is, “the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use.” While we agree on a definition, we also come to a fork in the road in terms of implementation, between an academic approach to usability and one that is more operational in nature.

To an academic/engineering audience, the concept of usability will look a lot like this. To most clinicians, IT staff, and informatics professionals in the trenches, their corresponding Venn diagram might contain very different words: documentation, standardization, analytics, culture, training, workflows, interdisciplinary collaboration, downtimes, infrastructure, policy, and informatics.  (I invite you to share your own words in the comments section of this post.)

But addressing the usability of electronic health records (EHRs) is the heart of the work done by informaticists – triage and translation. When called to address an issue with health IT, one must first triage the problem and determine if there is a true break/fix situation at hand (e.g., a button that doesn’t work or an order that displays incorrectly). I am certain I will not surprise any clinical informatics professionals when I say that most issues are not break/fix and won’t be addressed by tweaking a setting or a bit of code.

Similarly, many issues that are blamed on regulation are not actually related to regulatory requirements. Instead, many issues are the result of implementation decisions.  I like to say that a system will not be usable if you don’t know how to use it: a training, knowledge, or support deficiency often underlies inefficient use of the system. Many meetings called to address documentation burden, in the form of too many clicks, have little to do with the system and more to do with pre-implementation decisions such as customized content, mandatory fields, pop-up alerts, flow sheet rows, etc.

Implementation is key to usability – Nursing Informatics is key to optimization

Nursing informaticists transform the usability of health IT systems in their facilities and practices. Trained with a diverse set of tools to expertly triage and correct any system, workflow, training, and accountability issues, they lead the partnerships between their frontline clinicians, super users (i.e., bedside clinicians who receive additional health IT training), and IT clinical analysts and builders. Nurse informaticists possess the ability to mediate and moderate governance and interdisciplinary committees to align practice, health IT, analytics, and outcomes, and they are capable of significantly impacting the usability of health IT across the health care system. 

Take Becky Fox, MSN, RN, who led a three year project with her nursing informatics team to reduce assessment documentation time by 20 percent, eliminate 400,000 clicks within the on-time medication workflow, and eliminate over five million nursing tasks from the system (saving nurses 17.8 million clicks!).  Or Patricia Sengstack, DNP, RN-BC, FAAN, who investigated her admission assessment of 14 screens and 153 required fields, discovering that only 25 percent of the nursing data in the EHR was useful to nurses; rather, most of the data gathered in the EHR was neither read by fellow nurses nor other members of the care team.  Finally, Jane Englebright, PhD, RN, CENP, initiated a two year project called Evidence Based Clinical Documentation. This project returned up to two hours of time spent on nursing documentation to patient care in each 12 hour nursing shift.

Becky, Patty, and Jane’s efforts demonstrate that paired with an interdisciplinary informatics team, nursing informaticists are in a unique position to lead governance and usability efforts that significantly decrease clinician documentation burden. However, they must be well-trained, well-staffed, and well-supported by their organizations to do this critical work; fortunately for those teams, the Office of the National Coordinator for Health Information Technology (ONC) has resources that can help!

Resources are available

I will close with a bit of a confession – before coming to work for ONC, I never (not even once) used our resources for my implementation work. Imagine my surprise when I realized how much useful material there is! I was also amazed by the fact that public comment on our work is one of our key inputs for revisions and direction – to that end, please let us know how we’re doing by commenting on all of our proposals – I promise that we listen!

Here are five tools from ONC that can address some of the usability issues I shared today:

  1. We produced and updated the SAFER Guides – nine evidence-based checklists and risk assessment documents that allow facility-based teams to identify key areas for improvement.
  2. The Health IT Playbook, an interactive website full of resources that span the spectrum of health IT from EHRs to patient engagement to public health, was released late last year and is continually being updated.
  3. The EHR Contract Guide helps clinicians and hospitals understand the terms of the vendor contracts that they will review and sign as they acquire new health IT.
  4. With the HHS Office for Civil Rights, we released a series of brief, easy-to-understand videos that explain the Health Insurance Portability and Accountability Act (HIPAA) and the rights of individuals to access their own health information to help them and their care teams.
  5. We are also working on a Usability Change Package that will provide resources to end users in a variety of settings, as they seek to formally assess and improve the usability of their systems.

Our efforts and documents are living, breathing things! More importantly, they will be made better with input from you, the folks on the ground, working in the health IT trenches every day; we want to hear from you how we can help.

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