Click frustration is the psychological manifestations of repetitive clicks to the mouse button in a task. Click frustration is closely related to alert fatigue. While alert fatigue tends to be related to clinical decision support, click frustration deals more with the entire electronic medical record.
Click frustration is most prominent in a task which should not require repetitive mouse button clicks. For example, most prominent electronic medical record systems use a prescription writing program for ePrescribing. In one such system, to refill a medication, the following step must be taken:
- Login to the EMR
- 1 mouse click to launch the application
- 1 click to type a user name
- 1 click to type a password,
- 1 click to login
- Total: 4 clicks
- Select the patient
- 1 click to launch the search box
- 1 click to enter the medical record number
- 1 click to search
- 1 click to select the patient
- 1 click to select an encounter
- Total: 5 clicks
- Patient chart is open, find the medication
- 1 click to find the medication list
- 1 click to find the medication
- Total: 2 clicks
- Refill the medication
- 1-3 clicks to override alerts/reminders about …printers, inpatient vs outpatient, vs expired med, etc,
- 1 click to view the details tab
- 0 clicks to medication order – assume refill, no other changes like changing the number of refills, quantity or frequency,
- 1 click to open printer tab
- 1 click to select the printer [this system does not allow a default printer]
- 1 click to hit OK button,)
- Total 5-7 clicks (assuming refill only)
- Sign order
- 1click to go to order signature page
- 1 click to sign
- Total: 2 clicks
- Now the prescription is printed and must be manually signed.
This example, for refilling one medication, took a minimum of 16-18 click of the mouse. That does not account for time it took to load the application, no allergy alerts, no drug-drug interaction alerts, no changes to the original prescription. What was once a simple signature by the provider on the paper-chart, has now become a process, with a minimum of 16 clicks by the provider. This is by definition – click frustration.
While the process described above is the process currently used, it must be expressed that it is not an optimal process. There are a number of steps that could be streamlined to avoid click frustration, however, the goal of this article is not manage processes, but to define the frustrations that providers suffer while using the mouse clicks to interact with the electronic medical record. It should also be noted that paper based charts have a separate process for refills, one which allowed charts to be brought to the provider, a refill request on the top of the chart and only a signature or initials were needed to provide the refill.
There are distinct differences between the paper-based and electronic processes which account for some of the frustrations that provider encounter. It must be recognized that click frustration is not entirely a technical problem, but a frustration that occurs when inefficient electronic processes replace relatively time insensitive paper-based system. A relatively simple manual process becomes a time and labor intensive adventure with clicks. It is recognized that there are many more examples of click frustration in the current electronic medical records that exist and that many more click frustration processes will be implemented in the future, neither which offer excuses for the use who suffers from click frustration.
- Vashtz G (sp), Meyer J, Parmet Y, Peleg R, Goldfarb D, Porath A, Gilutz H. Defining and measuring physicians' responses to clinical reminders. J Biomed Inform. 2008 Oct 26.
- Varonen H, Kortteisto T, Kaila M; EBMeDS Study Group. What may help or hinder the implementation of computerized decision support systems (CDSSs): a focus group study with physicians. Fam Pract. 2008 Jun;25(3):162-7.
- Steele AW, Eisert S, Witter J, Lyons P, Jones MA, Gabow P, Ortiz E. The effect of automated alerts on provider ordering behavior in an outpatient setting. PLoS Med. 2005 Sep;2(9):e255.
- Overhage JM, Tierney WM, Zhou XH, McDonald CJ. A randomized trial of "corollary orders" to prevent errors of omission. J Am Med Inform Assoc. 1997 Sep-Oct;4(5):364-75.
- van der Sijs H, Aarts J, van Gelder T, Berg M, Vulto A. Turning off frequently overridden drug alerts: limited opportunities for doing it safely. J Am Med Inform Assoc. 2008 Jul-Aug;15(4):439-48.
- Ko Y, Abarca J, Malone DC, Dare DC, Geraets D, Houranieh A, Jones WN, Nichol WP, Schepers GP, Wilhardt M. Practitioners' views on computerized drug-drug interaction alerts in the VA system. J Am Med Inform Assoc. 2007 Jan-Feb;14(1):130-1.
- Weingart SN, Toth M, Sands DZ, Aronson MD, Davis RB, Phillips RS. Physicians' decisions to override computerized drug alerts in primary care. Arch Intern Med. 2003 Nov 24;163(21):2625-31.
- Coiera E, Westbrook J, Wyatt J. The safety and quality of decision support systems. Yearb Med Inform. 2006:20-5.
--Trevorrohm 15:11, 18 February 2009 (CST)
Submitted by Trevor Rohm