EHR usability has reached a tipping point. Clinicians can no longer absorb the cognitive burden associated with poorly designed software. To restore clinician wellness, the industry needs to rethink its approach to EHRs – from design, through deployment and optimization – to go beyond usability. We must create solutions that are more helpful to clinicians.
The human brain can process a lot of information, but we all have our limits. If software makes the user's task unnecessarily complex, it can lead to cognitive burden. This hidden tax can affect a clinician's efficiency and focus. One simple example might be a phone number that appears as 13125554613. This format is much harder to process than one that appears like this: (312) 555-4613.
While these "switch costs" may only be a few tenths of a second per item, they add up when users must switch repeatedly back and forth between tasks.[i] This activity limits cognitive resources, which can increase risk of error and can potentially affect patient safety.[ii] Designing EHRs with best user-centered design practices in mind can help remove these switch costs.
To improve the clinician experience, EHRs need to do more for their users. We've been enhancing our approach to EHR design to go beyond usability, because "useable" EHRs aren't always "helpful" EHRs. At Allscripts, we call this a Helper Philosophy in our design process. It means asking the right questions and getting to the root of the problem in each workflow – not just applying a new color scheme or reducing the number of clicks. It also means asking the question "what would make this MOST/MORE useful for the clinician?" and using this as a source of innovation.
Example: Re-design of Sunrise™ Compass
Compass, part of Allscripts Sunrise™ EHR platform, guides users to tasks that need to be done now and those that should be completed later, in the context of what the user is doing. By giving the right information at the right time, and only what is necessary, Compass helps clinicians become more efficient and avoid relying on memory.
Compass was made more helpful to users following a user-centered design initiative to improve the application and focus on helpfulness. Previously, it gave users too many options and forced them to look in several places within the application to find out what they needed to do for their patients. There were also several inconsistencies within the user interface, especially around tasks, that created cognitive burden.
The Allscripts User Experience (UX) team asked questions to get to the root of the issues: How do users do their work? What do users expect? How well is the current solution meeting those expectations? How can we simplify the user interface and make it more helpful to the user?
By involving the end user early and often, we developed some clear action steps. First, we did a better job of supporting the user definition of "tasks" and removed technical boxes that divvied up these items. Second, we brought these consolidated tasks to the user, sorted by priority, and introduced the ability to filter the list and view tasks in line with contextual information. Third, we recognized that providers are either working on a specific patient or are working on tasks for multiple patients between visits. Compass now offers a global module with all tasks and a patient-specific perspective.
Before-and-after testing revealed that 49 percent of users found Sunrise Compass more enjoyable, 40 percent found it more intuitive and 36 percent found it to be better at giving the right information at the right time. Allscripts uses the System Usability Scale (SUS), an industry standard and validated subjective measure of usability as a tool to evaluate our progress in UX projects. A score of 68 or higher is considered a target for subjective usability. Following this effort, the SUS score for Sunrise Compass improved from 36 to 87.
Some of these functional changes have removed a week or more of "click time" – time spent clicking, moving the mouse and waiting for info – every year. Less time on administrative tasks means more time providers can spend with their patients. This is just one example of our Helper Philosophy at work.
Continuous UX innovation and improvement
Allscripts has made a public commitment to clinician well-being[iii]. We prioritize product safety and usability, and we will support users with better insights, advice and ways to save time and effort. Industry recognition tells us we are on the right track. For example, the American Medical Association and MedStar Health recognized Allscripts for adhering to the best practices in user-centered design[iv].
Clinician burden is a complex, system problem with multiple contributing factors. By working in cooperation with stakeholders from across the industry, health IT vendors must develop and deploy solutions that help, not hinder clinicians. Rethinking our approach, and going beyond usability, is the first step.
[i] American Psychological Association. “Multitasking: Switching Costs” March 20, 2006
[ii] Wickens, C.D. (1984). “Processing resources in attention”, in R. Parasuraman & D.R. Davies (Eds.), Varieties of attention, (pp. 63–102). New York: Academic Press.
[iii] https://nam.edu/wp-content/uploads/2018/07/Allscripts_Commitment-Statementpdf.pdf
[iv] https://www.medicalhumanfactors.net/ehr-vendor-framework/#q=