Difference between revisions of "Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA"

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This is a review of Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA

Introduction

In recent years, the United States (US) has launched a far-reaching initiative to implement electronic health records (EHR) throughout the healthcare system. The fundamental goals of this initiative are to improve patient safety and decrease costs. As these systems are being implemented, more attention is being paid to the unintended consequences and the potential for harm. In 2012, the American Medical Informatics Association (AMIA) convened a task force with subcommittees to investigate the current state of the industry with respect to usability, productivity, and patient safety. Activities included literature searches, review of studies in progress within US federal agencies and federally funded projects, and evaluation of lessons learned in other high-tech, high-risk industries such as aviation. This article reported AMIA’s principle findings and recommendations.

Framework of Study

The task force’s framework included three concepts:

• Safe and effective use of EHR,
• EHR usability, and
• EHR usability-associated medical errors.

The task force concludes that optimal use of an EHR results from the integration of “application design, usability, human factors engineering, implementation, training, monitoring, and feedback”. Usability has been identified as one of the major factors affecting clinicians’ successful use of an EHR, including errors and the risk of adverse events. Sittig and Singh assert that EHR errors occur “anytime health IT is unavailable for use, malfunctions during use, is used incorrectly by someone, or when health IT interacts with another system component incorrectly, resulting in data being lost or incorrectly entered, displayed, or transmitted”.

Usability Recommendations

To address usability, AMIA’s recommendations build on three objectives: usability principles, use cases, and interface guidelines.

Usability Principles

First, usability concepts are referenced, including nine from the Healthcare Information Management and Systems Society (HIMSS) as well as additional factors described by Zhang and Walji of the National Center for Cognitive Informatics and Decision Making in Healthcare. These principles include the following:

• Design consistency
• Visibility of system state
• Real-world match
• Minimalism/simplicity
• Efficiency
• Minimization of cognitive load
• User feedback
• Flexibility/user control
• Definitive closure
• Reversibility/forgiveness
• Utilization of user language
• Effective presentation of information
• Availability of help

Use Cases

Secondly, AMIA recommends the development of eight standardized use cases to be used by EHR developers and certification bodies. These use cases emphasize EHR tasks that are most prone to causing patient harm including CPOE, clinical information reconciliation, as well as tasks involving medication prescribing, administration, allergies, contraindications, and drug-drug interactions.

Interface Guidelines

The third leg of AMIA’s usability recommendations includes the development of standard user interface guidelines, particularly for tasks that involve a high risk for patient harm. These standards would address features such as color, controls, layout, and application flow.

Challenges

AMIA recognizes the obstacles to implementing these recommendations, especially in the area of usability testing and evaluation. Challenges arise due to the complex socio-technical systems that involve software, organizational culture, and multiple users in various working environments separated by space and time. The authors suggest that much can be learned and emulated by studying the successes of the aviation industry which also grapples with high-risk situations and complex decision-making.

Summary

In summary, AMIA makes several recommendations targeted to specific stakeholders including vendors, the Office of the National Coordinator, National Institute of Standards and Technology, and the Agency for Healthcare Research and Quality. These recommendations include developing standardized methods and use cases for usability testing, promoting best practices, establishing a voluntary adverse event reporting process, developing an educational campaign on the safe and effective use of EHRs, developing a style guide for user interface design, performing usability testing on critical EHR functions, adopting system implementation best practices, and finally monitoring and reporting IT-related adverse events. AMIA aims to encourage ongoing dialogues and foster increased understanding of the effect of usability on patient safety and quality care, and promote wider coordination of activities that are currently underway as well as urge more to come.

References

Middleton, B., Bloomrosen, M., Dente, M. A., Hashmat, B., Koppel, R., Overhage, J. M., … Zhang, J. (2013). Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. Journal of the American Medical Informatics Association : JAMIA, 20(e1), e2–e8. doi:10.1136/amiajnl-2012-001458 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3715367/