What is human factors science and how can it improve EHRs?
Brandan P.Kennedy, M.D., FAAP
Health IT Trends
In the last two decades, electronic health records (EHRs) have significantly impacted
how the U.S. medical system provides health care and manages medical data. EHRs permeate
all levels of patient care in a highly complex social-technical system. They’ve contributed
to positive changes in health care, including improved quality, reliability and safety.
However, many EHRs were not designed with a clear understanding of clinical workflow
and health care environments. This has led to clinician frustration, burnout, adverse
patient safety events, drops in productivity and disruption of provider-patient interactions
Recently, there has been renewed focus on EHR functionality due to human factors science,
a social-technical systems approach that studies the way humans interact with the
world to continually improve that system. The integration of human factors into the
health care system brings potential for continued improvements in EHR design and functionality.
Consider an operating room (OR). Countless interactions occur among surgeons, nurses,
anesthesiologists, surgical instruments and technology during a surgical procedure:
role and workflow of each individual,
buttons pushed on a monitor or medical device and
mouse clicks or keystrokes on a computer.
In turn, each of those interactions is dictated by external factors such as culture,
organization and policy.
Human factors science is used to evaluate these interactions, including human-computer
interactions related to EHR use.
Two terms often used to discuss EHR design are usability and user experience.
Usability typically refers to specific product or interface design. Researchers assess
the efficiency, learnability, memorability, satisfaction and effort required to perform
necessary tasks. Products with good usability are intuitive, efficient and enjoyable
User experience refers to the global experience of using an EHR product. It encompasses
branding, product design and usability, and overall satisfaction. It also may include
service associated with an EHR.
EHRs initially were designed by information technology engineers with little understanding
of the socio-technical interactions required for expert patient care. In the last
five to 10 years, many EHR vendors have incorporated user experience experts and human
factors scientists into their solutions developments.
The question then arises: Why does it seem that EHR functionality improvements are
so painfully slow?
The reasons are complex, but some global issues include:
difficulty translating clinical functionality into the EHR;
amount of time required to redesign, recode, rebuild, evaluate and deploy new processes;
changing federal regulations that require vendors to prioritize meeting standards
rather than focusing on design improvements prioritized by clinical staff;
standardization vs. customization; and
costs related to developing and incorporating new technologies, system upgrades and
EHR developers are working to speed up the improvement process. One approach is iterative
design: using rapid development cycles with early release of solutions, followed by
user feedback and continuous development. This provides faster cycles of new workflow
designs. However, early design stages often have incomplete workflows that are not
very usable until further iterations are provided.
Another recent development is the creation of native apps that can be “added on” to
the EHR. An example is SMART (Substitutable Medical Applications and Reusable Technologies)
on FHIR (Fast Health Information Resources) apps, which are developed relatively quickly
and can improve clinical workflow and processes in the EHR. There are several free,
open source pediatric SMART apps, including those that assist in diabetes management,
growth charts and automated blood pressure assessment. There also is a considerable
amount of activity in the development of voice activated/controlled integration into
Improving EHR usability and user experience is a massive undertaking. It requires
interdisciplinary teams of experts, including clinicians, software engineers, human
factors engineers, user experience experts and other stakeholders. Health care systems,
academic experts and industry champions need to collaborate and assist EHR developers
to shorten translation time for new software designs that will integrate more effectively
with how health care providers do their work.
Dr. Kennedy is a member of the AAP Council on Clinical Information Technology.Sarah Fouquet, Ph.D., Y. Raymond Chan, M.D., M.S., FAAP, and Eryn M. Godwin, B.A.,
contributed to this article.