Usability problems do not heal by themselves : National survey on physicians' experiences with EHRs in Finland

Purpose: Survey studies of health information systems use tend to focus on availability of functionalities, adoption and intensity of use. Usability surveys have not been systematically conducted by any healthcare professional groups on a national scale on a repeated basis. This paper presents results from two cross-sectional surveys of physicians' experiences with the usability of currently used EHR systems in Finland. The research questions were: To what extent has the overall situation improved between 2010 and 2014? What differences are there between healthcare sectors? Methods: In the spring of 2014, a survey was conducted in Finland using a questionnaire that measures usability and respondents' user experiences with electronic health record (EHR) systems. The survey was targeted to physicians who were actively doing clinical work. Twenty-four usability-related statements, that were identical in 2010 and 2014, were analysed from the survey. The respondents were also asked to give an overall rating of the EHR system they used. The study data comprised responses from 3081 physicians from the year 2014 and from 3223 physicians in the year 2010, who were using the nine most commonly used EHR system brands in Finland. Results: Physicians' assessments of the usability of their EHR system remain as critical as they were in 2010. On a scale from 1 ('fail') to 7 ('excellent') the average of overall ratings of their principally used EHR systems varied from 3.2 to 4.4 in 2014 (and in 2010 from 2.5 to 4.3). The results show some improvements in the following EHR functionalities and characteristics: summary view of patient's health status, prevention of errors associated with medication ordering, patient's medication list as well as support for collaboration and information exchange between the physician and the nurses. Even so, support for cross-organizational collaboration between physicians and for physician-patient collaboration were still considered inadequate. Satisfaction with technical features had not improved in four years. The results show marked differences between the EHR system brands as well as between healthcare sectors (private sector, public hospitals, primary healthcare). Compared to responses from the public sector, physicians working in the private sector were more satisfied with their EHR systems with regards to statements about user interface characteristics and support for routine tasks. Overall, the study findings are similar to our previous study conducted in 2010. Conclusions: Surveys about the usability of EHR systems are needed to monitor their development at regional and national levels. To our knowledge, this study is the first national eHealth observatory questionnaire that focuses on usability and is used to monitor the long-term development of EHRs. The results do not show notable improvements in physician's ratings for their EHRs between the years 2010 and 2014 in Finland. Instead, the results indicate the existence of serious problems and deficiencies which considerably hinder the efficiency of EHR use and physician's routine work. The survey results call for considerable amount of development work in order to achieve the expected benefits of EHR systems and to avoid technology-induced errors which may endanger patient safety. The findings of repeated surveys can be used to inform healthcare providers, decision makers and politicians about the current state of EHR usability and differences between brands as well as for improvements of EHR usability. This survey will be repeated in 2017 and there is a plan to include other healthcare professional groups in future surveys. (C) 2016 The Authors. Published by Elsevier Ireland Ltd.Peer reviewe

The development and implementation of e-health services for the Libyan NHS: case studies of hospitals and clinics in both urban and rural areas

This thesis provides an assessment of the readiness levels within both urban and rural hospitals and clinics in Libya for the implementation of E-health systems. This then enabled the construction of a framework for E-health implementation in the Libyan National Health Service (LNHS). The E-health readiness study assessed how medications were prescribed, how patients were referred, how information communication technology (ICT) was utilised in recording patient records, how healthcare staff were trained to use ICT, and how the ways in which consultations were carried out by healthcare staff. The research was done in five rural clinics and five urban medical centres and focused on the E-health readiness levels of the technology, social attitudes, engagement levels and any other needs that were apparent. Collection of the data was carried out using a mixed methods approach with qualitative interviews and quantitative questionnaires. The study indicated that any IT equipment present was not being utilised for clinical purposes and there was no evidence of any E-health technologies being employed. This implies that the maturity level of the healthcare institutions studied was at level zero in the E-health maturity model used in this thesis. In order for the LNHS to raise its maturity levels for the implementation of E-health systems, it needs to persuade LNHS staff and patients to adopt E-health systems. This can be carried out at a local level throughout the LNHS, though this will need to be coordinated at a national level through training, education and programmes to encourage compliance and providing incentives. In order to move E-health technology usage in the participating Libyan healthcare institutions from Level 0 to Level 2 in the E-health Maturity Model levels, an E-health framework was created that is based on the findings of this research study. The primary aim of the LNHS E-Health Framework is the integration of E-health services for improving the delivery of healthcare within the LNHS. To construct the framework and ensure that it was creditable and applicable, work on it was informed directly by the findings from document analysis, literature review, and expert feedback, in conjunction with the primary research findings presented in Chapter Five. When the LNHS E-Health Framework was compiled there were several things taken into consideration, such as: the abilities of healthcare staff, the needs of healthcare institutions and the existing ICT infrastructure that had been recorded in the E-readiness assessment which was carried out in the healthcare institutions (Chapter 5). The framework also provides proposals for E-health systems based on the infrastructure network that will be developed. The processes addressed are electronic health records, E-consultations, E-prescriptions, E-referrals and E-training. The researcher has received very positive, even enthusiastic, feedback from the LNHS and other officals, and that expect the framework to be further developed and implemented by the LNHS in the near future

Usability analysis of contending electronic health record systems

In this paper, we report measured usability of two leading EHR systems during procurement. A total of 18 users participated in paired-usability testing of three scenarios: ordering and managing medications by an outpatient physician, medicine administration by an inpatient nurse and scheduling of appointments by nursing staff. Data for audio, screen capture, satisfaction rating, task success and errors made was collected during testing. We found a clear difference between the systems for percentage of successfully completed tasks, two different satisfaction measures and perceived learnability when looking at the results over all scenarios. We conclude that usability should be evaluated during procurement and the difference in usability between systems could be revealed even with fewer measures than were used in our study. © 2019 American Psychological Association Inc. All rights reserved.Peer reviewe

Designing an architecture for secure sharing of personal health records : a case of developing countries

Includes bibliographical references.While there has been an increase in the design and development of Personal Health Record (PHR) systems in the developed world, little has been done to explore the utility of these systems in the developing world. Despite the usual problems of poor infrastructure, PHR systems designed for the developing world need to conform to users with different models of security and literacy than those designed for developed world. This study investigated a PHR system distributed across mobile devices with a security model and an interface that supports the usage and concerns of low literacy users in developing countries. The main question addressed in this study is: “Can personal health records be stored securely and usefully on mobile phones?” In this study, mobile phones were integrated into the PHR architecture that we/I designed because the literature reveals that the majority of the population in developing countries possess mobile phones. Additionally, mobile phones are very flexible and cost efficient devices that offer adequate storage and computing capabilities to users for typically communication operations. However, it is also worth noting that, mobile phones generally do not provide sufficient security mechanisms to protect the user data from unauthorized access

Front-Line Physicians' Satisfaction with Information Systems in Hospitals

Day-to-day operations management in hospital units is difficult due to continuously varying situations, several actors involved and a vast number of information systems in use. The aim of this study was to describe front-line physicians' satisfaction with existing information systems needed to support the day-to-day operations management in hospitals. A cross-sectional survey was used and data chosen with stratified random sampling were collected in nine hospitals. Data were analyzed with descriptive and inferential statistical methods. The response rate was 65 % (n = 111). The physicians reported that information systems support their decision making to some extent, but they do not improve access to information nor are they tailored for physicians. The respondents also reported that they need to use several information systems to support decision making and that they would prefer one information system to access important information. Improved information access would better support physicians' decision making and has the potential to improve the quality of decisions and speed up the decision making process.Peer reviewe

Interdisciplinary systematic review: does alignment between system and design shape adoption and use of barcode medication administration technology?

BACKGROUND: In order to reduce safety risks associated with medication administrations, technologies such as barcode medication administration (BCMA) are increasingly used. Examining how human factors influence adoption and usability of this technology can potentially highlight areas for improvement in design and implementation. OBJECTIVE: To describe how human factors related determinants for BCMA have been researched and reported by healthcare and human-computer interaction disciplines. DATA SOURCES: The Cumulative Index of Nursing, and Allied Health Literature, PubMed, OVID MEDLINE and Google Scholar. STUDY ELIGIBILITY CRITERIA: Primary research published from April 2000 to April 2020, search terms developed to identity different disciplinary research perspectives that examined BCMA use, used a human factors lens and were published in English. SYNTHESIS METHODS: Computerised systematic searches were conducted in four databases. Eligible papers were systematically analysed for themes. Themes were discussed with a second reviewer and supervisors to ensure they were representative of content. RESULTS: Of 3707 papers screened, 11 were included. Studies did not fit neatly into a clinical or human-computer interaction perspective but instead uncovered a range of overlapping narratives, demonstrating consensus on the key themes despite differing research approaches. Prevalent themes were misaligned design and workflow, adaptation and workarounds, mediating factors, safety, users' perceptions and design and usability. Inadequate design frequently led to workarounds, which jeopardised safety. Reported mediating factors included clarity of user needs, pre/post implementation evaluations, analysis of existing workarounds and appropriate technology, infrastructure and staffing. LIMITATIONS: Most studies were relatively small and qualitative, making it difficult to generalise findings. CONCLUSION: Evaluating interdisciplinary perspectives including human factors approaches identified similar and complementary enablers and barriers to successful technology use. Often, mediating factors were developed to compensate for unsuitable design; a collaborative approach between system designer and end users is necessary for BCMA to achieve its true safety potential

Creating archetypes for patient assessment with nurses to facilitate shared patient centred care in the older person

The process of what information is captured in documenting patient care assessment and how it is summarised, communicated and interpreted by nurses across different healthcare services is the main focus of this thesis. Currently in Ireland, systems within the domain of healthcare are undergoing transformation. Existing practices where health information is collected at one local health organisation level and often duplicated across differing services will not support the strategic goals of the newly established clinical directorates. The political vision is simple: Ireland must move towards a nationally integrated electronic record to support patient centred care. Whilst the political vision may be simple, the process of implementation is not and forms the main topic of this thesis. Strategic goals to move nationally towards integrated electronic records are motivated by the global concerns of an ageing population associated with an increase in the prevalence of chronic illness and co-morbidity. The main objective of this thesis is to evaluate the impact of a pilot study which identified the semantic and syntactic clinical requirements for the testing and implementation of a shared discharge/transfer summary assessment record for persons over the age of 65. This summary record was designed in accordance with ISO 13606, the International standard for Electronic Healthcare Record (EHR) communication and is underpinned by ISO 18104, the international standard for Categorial Structures for Representation of Nursing Diagnosis and Nursing Actions in Terminological Systems. A participatory action research approach was adopted, using an exploratory mixed methods research study design. This translational study was completed in two local health organisation areas in Dublin with six service providers across the primary, acute and continuing care services over a two year period. The qualitative element of the study involved 17 interviews, 7 focus group sessions with participants including policy makers and nurses from each of the participating services. Quantitative data included questionnaires from nurses (n = 14) and patients (n=5) evaluating the effectiveness of the summary record. The quantitative data also analysed information from a set of cumulative assessment records (n = 16) which were interpreted in tandem with the qualitative data and then analysed statistically. The shared discharge/transfer summary care record was piloted on 16 patients over an extended timeframe. The quantitative data showed a statistical significance commensurate with the qualitative data collected on patient participants. An evaluation of the pilot study produced qualitative data which was used to gain insight into the differing contexts that healthcare professionals practice within. This data was illustrated in graphical configurations to make evident to policy makers the various roles that nurses engage with in the course of their care delivery. Data collected from both the qualitative and quantitative analysis suggest that the test implementation of the record template was fit for purpose. Identification of the clinical requirements and testing of the summary record over a two year period was a labour intensive process which was logistically difficult to implement. One consequence of this study was the education of the nursing participants on gaining a common understanding of what needs to be measured in patient assessment to inform future theory testing for outcome based research. A second consequence was the empowerment of the nursing participants to develop archetypes for inclusion in future electronic healthcare records in Ireland. The prototype archetypes designed for assessment of the older person in this study are at present informing a number of practical applications within the nursing community in Ireland. Over the course of the study the participatory action research design altered in its focus and emerged as a dominant qualitative mixed methods study

Doctor of Philosophy

dissertationClinical decision support systems (CDSS) and electronic health records (EHR) have been widely adopted but do not support a high level of reasoning for the clinician. As a result, workflow incongruity and provider frustrations lead to more errors in reasoning. Other successful fields such as defense, aviation, and the military have used task complexity as a key factor in decision support system development. Task complexity arises during the interaction of the user and the tasks. Therefore, in this dissertation I have utilized different human factor methods to explore task complexity factors to understand their utility in health information technology system design. The first study addresses the question of generalizing complexity through a clinical complexity model. In this study, we integrated and validated a patient and task complexity model into a clinical complexity model tailored towards healthcare to serve as the initial framework for data analysis in our subsequent studies. The second study addresses the question of the coping strategies of infectious disease (ID) clinicians while dealing with complex decision tasks. The study concluded that clinicians use multiple cognitive strategies that help them to switch between automatic cognitive processes and analytical processes. The third study identified the complexity contributing factors from the transcripts of the observations conducted in the ID domain. The clinical complexity model developed in the first study guided the research for identifying the prominent complexity iv factors to recommend innovative healthcare technology system design. The fourth study, a pilot exploratory study, demonstrated the feasibility of developing a population information display from querying real complex patient information from an actual clinical database as well as identifying the ideal features of population information display. In summary, this dissertation adds to the knowledge about how clinicians adapt their information environment to deal with complexity. First, it contributes by developing a clinical complexity model that integrates both patient and task complexity. Second, it provides specific design recommendations for future innovative health information technology systems. Last, this dissertation also suggests that understanding task complexity in the healthcare team domain may help to better design of interface system

Guidelines for the user interface design of electronic medical records in optometry

With the prevalence of digitalisation in the medical industry, e-health systems have largely replaced the traditional paper-based recording methods. At the centre of these e-health systems are Electronic Health Records (EHRs) and Electronic Medical Records (EMRs), whose benefits significantly improve physician workflows. However, provision for user interface designs (UIDs) of these systems have been so poor that they have severely hindered physician usability, disrupted their workflows and risked patient safety. UID and usability guidelines have been provided, but have been very high level and general, mostly suitable for EHRs (which are used in general practices and hospitals). These guidelines have thus been ineffective in applicability for EMRs, which are typically used in niche medical environments. Within the niche field of Optometry, physicians experience disrupted workflows as a result of poor EMR UID and usability, of which EMR guidelines to improve these challenges are scarce. Hence, the need for this research arose, aiming to create UID guidelines for EMRs in Optometry, which will help improve the usability of the optometrists’ EMR. The main research question was successfully answered to produce the set of UID Guidelines for EMRs in Optometry, which includes guidelines built upon from literature and made contextually relevant, as well as some new additions, which are more patient focused. Design Science Research (DSR) was chosen as a suitable approach, and the phased Design Science Research Process Model (DSRPM) was used to guide this research. A literature review was conducted, including EHR and EMR, usability, UIDs, Optometry, related fields, and studies previously conducted to provide guidelines, frameworks and models. The review also included studying usability problems reported on the systems and the methods to overcome them. Task Analysis (TA) was used to observe and understand the optometrists’ workflows and their interactions with their EMRs during patient appointments, also identifying EMR problem areas. To address these problems, Focus Groups (FGs) were used to brainstorm solutions in the form of EMR UID features that optometrists’ required to improve their usability. From the literature review, TAs and FGs, proposed guidelines were created. The created guidelines informed the UID of an EMR prototype, which was successfully demonstrated to optometrists during Usability Testing sessions for the evaluation. Surveys were also used for the evaluation. The results proved the guidelines were successful, and were usable, effective, efficient and of good quality. A revised, final set of guidelines was then presented. Future researchers and designers may benefit from the contributions made from this research, which are both theoretical and practical