Staggers, N. & Makar, E. (Feb, 2017). National Efforts in 2016 to Improve Health IT Usability. Online Journal of Nursing Informatics (OJNI), 21(1). Available at http://www.himss.org/ojni
Usability pain points are felt by nurses and physicians world wide (Staggers, Elias, Hunt, Makar & Alexander, 2015; AMA, 2014). With the widespread deployment of electronic health records (EHRs) and other electronic devices, poor health IT usability has become a critical issue across disciplines and health organizations. Two recent workshops were held that have direct relevance for solving health IT usability issues. The first conference was at the National Institutes of Standards and Technology (NIST) on September 7, 2016, and the second was held a day later by the Association for the Advancement of Medical Instrumentation (AAMI). Both had nursing representation. The main points of relevance to nurses are summarized here.
The purpose of this day-long workshop was to outline how standards might prevent or mitigate health IT patient safety risks. Co-sponsors of the event included AAMI and the Office of the National Coordinator (ONC) for Health IT. The interdisciplinary set of speakers gave short presentations about a wide variety of issues. Readers can view speaker slides at https://www.nist.gov/node/1073696. Three themes of interest to nurses emerged: (1) solutions to poor usability are a shared responsibility, (2) nursing’s usability solutions represent an unmet need, and (3) beginning work is underway at the national level.
Speakers agreed that no one organization or profession could solve current usability pain points. The way forward will entail collaboration across professions and organizations. Health professionals, Human Factors, IT professionals and health care administrators will need to be central participants in solutions. Likewise, professional organizations and government agencies will need to collaborate on solutions.
What were not yet discussed is how this collaboration might occur and which organization might take the lead in coordinating efforts. At least these national organizations are currently engaged in usability efforts: NIST, AAMI, ONC and HIMSS (Health Information Management and Systems Society). NIST and AAMI are focusing on developing standards including standard processes for usability. The ONC has developed basic usability references (see usability.gov) and HIMSS also has a set of reference documents including EHR testing guides and information on maturing usability in organizations (see https://www.scribd.com/document/17227201/HIMSS-EHR-Usability-Task-Force-Report-on-Defining-and-Testing-EMR-Usability and http://www.himss.org/himss-usability-maturity-model, respectively).
Nursing HIT Pain Points Are An Unmet Need
The first author made three strong messages in a short, nine-minute presentation: (1) design for nurses, (2) design for the ecosystem, and (3) design for situation awareness. First, health IT designs need to focus on nurses because they are the largest group of health IT users at 3.6 million in the U.S. alone (McMenamin, 2016). Nurses are the profession closest to patients in acute and long-term care, and we detect patient issues early. Current designs do not support our workflow and decision-making (Staggers, Elias, Hunt, Makar & Alexander, 2016). Second, we need future designs to consider whole work processes using the view of the ecosystem. For example, medication management processes need to be considered from order entry through pharmacy processing to medication administration and subsequent assessment and decision-making of RNs. More importantly, an ecosystem view would incorporate communication processes around medications, currently a separate and isolated process using telephony. Third, designing for situation awareness means providing the pertinent information at the right time in a format that allows for quick information detection. For instance, medication management might have a visual display that highlights related lab, vital sign, and recent symptoms for a specific patient for a specific medication at a specific delivery time. New orders and results would be sent to mobile devices for viewing in an easily recognizable format, graded by severity, for instance. Data visualization techniques are used outside healthcare and need to be incorporated into next-generation health IT designs (Zulman, Shah & Verghese, 2016). These designs would be built on work analyses that provide a deep understanding of nurses’ work and where it intersects with multidisciplinary teams.
Beginning National Work
The National Quality Forum in conjunction with ONC released a report in February 2016 entitled “Identification and Prioritization of Health IT Patient Safety Measures.” The purpose of the report was to provide a conceptual framework and direction for the development of health IT Safety Measures. See the full report at: http://www.qualityforum.org/Publications/2016/02/Identification_and_Prioritization_of_HIT_Patient_Safety_Measures.aspx.)
NQF’s panel recommended measuring health IT safety using a sociotechnical framework promoted by Sittig and Singh (2010). This framework considers safety domain principles such as correct health IT use and optimization in a structured process that measures health IT impacts to improve safer health IT-enabled healthcare. High priority areas for measurement included clinical decision support, interoperability, patient identification, downtime, and user-centered design processes including the use of testing, evaluation and simulation.
AAMI is in the process of convening four workgroups to address health IT software and systems standards:
- Fundamental concepts and principles. For example, AAMI will define roles and responsibilities and the health IT system life cycle
- Application of quality systems principles and practices
- Application of risk management
- Application of human factors engineering
These efforts are encouraging, even if the approach is clearly over the long term. Usability concerns have reached a tipping point in the U.S. Fortunately, nursing representation is active on the AAMI committees, at NIST and at the NQF. Upcoming efforts will need to be harmonized, but we are building traction to provide solutions for nursing pain points with health IT. We encourage all nurses in informatics and all specialty areas to keep abreast of opportunities and to weigh in on this important subject.
Nancy Staggers, PhD, RN, FAAN, is the president, Summit Health Informatics, and adjunct professor, University of Utah. firstname.lastname@example.org
Ellen Makar, MSN, RN-BC, CCM, CPHIMS, CENP, is a senior research scientist, Battelle, email@example.com
Smith, M. (2013). AMA Board Chair: HHS should address EHR usability issues immediately [Blog post]. Retrieved from http://blog.thecamdengroup.com/blog/bid/292821/AMA-Board-Chair-HHS-Should-Address-EHR-Usability-Issues-Immediately
McMenamin, P. (2016). Voice of 3.6 million nurses and still counting [Blog post]. Retrieved from http://community.ana.org/blogs/peter-mcmenamin/2016/09/19/three-point-six-million-registered-nurses?ssopc=1
Sittig, D. F. & Singh, H. (2010). A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Quality & Safety in Health Care, 19(Supp 3), i68-i74. https://doi.org/10.1136/qshc.2010.042085
Staggers, N., Elias, B. L., Hunt, J. R., Makar, E. & Alexander, G. L. (2015). Nursing-centric technology and usability a call to action. CIN: Computers Informatics Nursing, 33(8), 325-332. https://doi.org/10.1097/cin.0000000000000180
Staggers, N., Elias, B., Makar, E., Hunt, J., & Alexander, G. L. (2016). Identifying nurses’ health IT pain points and solutions: Preliminary findings. Paper presented at 10th International Conference UACHI 2016. Human-Computer Interaction International 2016. Held as part of HCI International 2016. Toronto, ON, Canada.
Zulman, D. M., Shah, N. H., & Verghese, A. (2016). Evolutionary pressures on the electronic health record: Caring for complexity. Journal of the American Medical Association, 316(9), 923-924. https://doi.org/10.1001/jama.2016.9538