Abstract
Current electronic health record (EHR) user interfaces are suboptimally designed and may be associated with excess cognitive workload and poor performance. To assess the association between the usability of an EHR system for the management of abnormal test results and physicians' cognitive workload and performance levels. This quality improvement study was conducted in a simulated EHR environment. From April 1, 2016, to December 23, 2016, residents and fellows from a large academic institution were enrolled and allocated to use either a baseline EHR (n = 20) or an enhanced EHR (n = 18). Data analyses were conducted from January 9, 2017, to March 30, 2018. The EHR with enhanced usability segregated in a dedicated folder previously identified critical test results for patients who did not appear for a scheduled follow-up evaluation and provided policy-based decision support instructions for next steps. The baseline EHR displayed all patients with abnormal or critical test results in a general folder and provided no decision support instructions for next steps. Cognitive workload was quantified subjectively using NASA-Task Load Index and physiologically using blink rates. Performance was quantified according to the percentage of appropriately managed abnormal test results. Of the 38 participants, 25 (66%) were female. The 20 participants allocated to the baseline EHR compared with the 18 allocated to the enhanced EHR demonstrated statistically significantly higher cognitive workload as quantified by blink rate (mean [SD] blinks per minute, 16 [9] vs 24 [7]; blink rate, -8 [95% CI, -13 to -2]; P = .01). The baseline group showed statistically significantly poorer performance compared with the enhanced group who appropriately managed 16% more abnormal test results (mean [SD] performance, 68% [19%] vs 98% [18%]; performance rate, -30% [95% CI, -40% to -20%]; P < .001). Relatively basic usability enhancements to the EHR system appear to be associated with better physician cognitive workload and performance; this finding suggests that next-generation systems should strip away non-value-added EHR interactions, which may help physicians eliminate the need to develop their own suboptimal workflows.
Highlights
The usability of electronic health records (EHRs) continues to be a major concern.[1,2,3] Usability challenges include suboptimal design of interfaces that have confusing layouts and contain either too much or too little relevant information as well as workflows and alerts that are burdensome
The 20 participants allocated to the baseline EHR compared with the 18 allocated to the enhanced EHR demonstrated statistically significantly higher cognitive workload as quantified by blink rate
Relatively basic usability enhancements to the EHR system appear to be associated with better physician cognitive workload and performance; this finding suggests that next-generation systems should strip away non–value-added EHR interactions, which may help physicians eliminate the need to develop their own suboptimal workflows
Summary
The usability of electronic health records (EHRs) continues to be a major concern.[1,2,3] Usability challenges include suboptimal design of interfaces that have confusing layouts and contain either too much or too little relevant information as well as workflows and alerts that are burdensome. Suboptimal usability has been associated with clinician burnout and patient safety events, and improving the usability of EHRs is an ongoing need.[4,5]. Even in the EHR environment, with alerts and reminders in place, physicians continue to often inappropriately manage abnormal test results.[12,13,14,15,16,17,18,19,20,21] Some key remaining barriers to effective management of test results are suboptimal usability of existing EHR interfaces and the high volume of abnormal test result alerts, especially lesscritical alerts that produce clutter and distract from the important ones.[22,23] In addition, few organizations have explicit policies and decision support systems in their EHR systems for managing abnormal test results, and many physicians have developed processes on their own.[24,25,26] These issues are among the ongoing reasons to improve the usability of the EHR-based interfaces for the evaluation and management of abnormal test results
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