January 27, 2020
Electronic health records were supposed to revolutionise clinical care. Enabled by advanced technology, EHR systems could transform the way we deliver care to patients with better precision, deeper insights, and at an optimal cost. Yet strategic decision about system interface design all too often becomes only a footnote in the broader discussion of EHR usability. This ignorance must change – system interface must become the centrepiece of EHR design.
Healthcare lags behind other major industries in digitisation for at least a decade. It is not surprising that the industry may be even further from deploying systems with sound interface design. Unlike the retail industry, the sheer amount of information in healthcare obviates the adoption of minimalist layout. Presenting too few information risks leaving out critical patient information; Similarly, an excessive juxtaposition of data may overwhelm physicians and lead to undue cognitive burdens.
The industry also suffers severe myopic vision – the willful ignorance of good interface design to better focus on the underlying EHR functions. While healthcare still suffers from the basic problem of ensuring EHR functions as intended, it is no wonder that system interface design is sacrificed. If we cannot make sure a car runs well, why would we worry about its look at all?
EHR user interface: a misplaced focus
One of the most critical oversights of EHR development was neglecting the impact of increased “click burden” on healthcare providers. Poor usability and appalling workflow integration have led to lengthy steps to perform simple tasks. Studies have shown that increased “click burden” is a source of frustration for physicians with little added clinical value (1). Inappropriately designed EHR have a roughly six-fold greater number of clicks and screen transitions to navigate to the required patient information compared to systems that aggregate relevant information into a single screen (2).
Additionally, navigation-related topics should be the prime concern in EHR usability investigation. A recent paper published in the Journal of Biomedical Informatics indicated that the majority of EHR system employed the cumbersome multi-page navigation method instead of the sleek one-page design. Navigation is a crucial aspect of EHR interface as individual patient information is likely to be scattered across multiple sections of the systems. Therefore, multi-page design forces physicians to act as temporary “information retainer” while they scroll through pages of irrelevant data in search of the necessary clinical information. This is analogous to attempts to capture the view of an entire room while peeping through the keyhole – a phenomenon coined as “display fragmentation” by the Institute of Medicine (National Academy of Medicine) (3).
Display fragmentation warrants immediate corrective action as these inefficiencies may bring catastrophic consequences. Physician burnout is among the greatest threats posed by fragmented EHR systems that are not clinician-centric. According to a report published by the RAND Corporation, physicians are especially put off by cumbersome data-entry tasks, who need to work beyond normal hours to complete their clerical work. Non-intuitive user interfaces and the lack of interoperability between electronic systems are also cited as the top reasons contributing to burnout (4,5)
The evidence-based approach to a good interface
So what constitutes a good EHR interface? The key features of good design are the adherence to the minimal “click burden” principle and the capacity to display comprehensive patient information – including composite parameters that are validated – in one screen (6). In other words, it must be clinician-centric and simple to use.
It is paramount to understand that simplicity does not equal the lack of complexity. This is particularly pertinent to healthcare. To design an EHR that is simple and safe, we must dig deep into each element of the system and truly understand the functions to produce solutions that are both pragmatic and elegant. For example, in the latest generation of COSMIC Medication Module, physicians can navigate to any medication screen with a maximum of two mouse clicks. Patient data such as vital signs, medications, allergies, and historical prescriptions will be displayed on the same screen to minimise “click burden”.
All in all, the EHR interface design cannot be taken lightly. Healthcare organisations should never, nor they can afford to, tolerate mediocre EHR systems – patients’ lives are at stake, after all, in this life-and-death business.
- Electronic health record innovations: Helping physicians – One less click at a time. – PubMed – NCBI [Internet]. [cited 2019 Nov 9]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28671038
- Senathirajah Y, Wang J, Borycki E, Kushniruk A. Mapping the Electronic Health Record: A Method to Study Display Fragmentation. Stud Health Technol Inform. 2017;245:1138–42.
- Committee on Patient Safety and Health Information Technology, Institute of Medicine. Health IT and Patient Safety: Building Safer Systems for Better Care [Internet]. Washington (DC): National Academies Press (US); 2011 [cited 2019 Nov 9]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK189661/
- Friedberg MW, Chen PG, Van Busum KR, Aunon F, Pham C, Caloyeras JP, et al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy: [Internet]. 2013 [cited 2019 Nov 9]. Available from: https://www.rand.org/pubs/research_reports/RR439.html
- Collier R. Electronic health records contributing to physician burnout. CMAJ Can Med Assoc J. 2017 Nov 13;189(45): E1405–6.
- West VL, Borland D, Hammond WE. Innovative information visualization of electronic health record data: a systematic review. J Am Med Inform Assoc JAMIA. 2015 Mar;22(2):330–9.