Controversy Over Creating National Measures for EHR Usability

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Crucial Conversations about Optimal Design Column

by Dr Nancy Staggers, Senior Editor

This column was made possible by an educational grant from

Chamberlain College of Nursing


Staggers, N. (October, 2011). Controversy Over Creating National Measures for EHR Usability. Crucial Conversations about Optimal Design Column. Online Journal of Nursing Informatics (OJNI),15 (3). Available at http://ojni.org/issues/?p=854


Crucial Conversations about Optimal Design ColumnU.S national efforts on improving electronic health records (EHR) usability are gaining momentum. In 2010, the National Institute of Standards and Technology (NIST) accepted responsibility for creating national standards and measures on EHR usability.

Their statement on intended efforts is as follows:

The NIST health IT Usability initiative is focused on establishing a framework that defines and assesses health IT usability. The goal of the research effort, being conducted in collaboration with the Office of the National Coordinator for Health Information Technology (ONC) and the Agency for Healthcare Research and Quality (AHRQ), is to create a detailed specification of an objective, repeatable procedure for measuring and evaluating the usability of health IT systems. The initiative will examine the human factors critical to designing usable EHRs and will guide industry in usability engineering practices. The research findings will be used to support the development and evaluation methods for these standards. (http://www.nist.gov/healthcare/usability/)

The agency held a conference in June 2011 toward the stated goals of measuring and evaluating EHR usability. The conference was intended as a community-building meeting across industry, academe, healthcare providers, usability professionals and federal agencies. Overall, NIST indicated that the day-long workshop was to serve as a forum for open discussions about the content and technical aspects of usability evaluation methods. All presentation slides are available at: http://www.nist.gov/healthcare/usability/usability-presentations.cfm.

Several areas are particularly pertinent to nursing informatics. Usability expert Ben Shneiderman made a forceful call for the transparent usability testing of EHR products. He recommended external, objective product evaluations once EHR guidelines and usability standards are published and indicated that common user interface guidelines would promote consistency. Further, he proposed publically-available reports of the results including failures. This kind of transparency mimics testing and reporting in the aviation and nuclear regulatory agencies and, from the provider and consumer perspective, could improve EHR safety.

Speakers offered available measures and frameworks for assessing EHR usability. Jiajie Zhang provided concrete measures ranging from time on task, number of steps and task success to user satisfaction. Other measures were consistent behaviors, common terminology and metaphors, equivalent help/efficiency tools and unnecessary redundancies outlined by Anjum Chagpar. Finally, The Ohio State University group shared an EHR Usability Safety Framework used for internal EHR evaluations; the framework is comprised of these elements:

  • Use errors (e.g., patient ID errors, data accuracy error or feedback error)
  • Patient harm (e.g., “never events”)
  • Evaluative indicators (e.g., workarounds, redundancies)
  • Risk factors (e.g., severity, frequency)

From the clinician perspective, Lyle Berkowitz, MD, translated how future user interfaces might improve cognitive support for clinicians when they complete tasks such as viewing multiple patient problems. Current interfaces are often similar to this view:

Figure 1: Example of clinical Interface

Figure 1: Example of clinical Interface

Dr. Berkowitz offered a future view of the same content (publically available at http://www.nist.gov/healthcare/usability/usability-presentations.cfm).

Figure 2: Dr. Berkowitz's Alternative Interface

Figure 2: Dr. Berkowitz's Alternative Interface

Or an even more avant-garde visual depiction:

Figure 3: Dr. Berkowitz's Avante Garde Interface Version

Figure 3: Dr. Berkowitz's Avante Garde Interface Version

Despite the informative presentations, the information was unevenly received by industry representatives. The afternoon discussions indicated that vendors:

  • Had misgivings about the whole notion of government being involved in guiding the usability of commercial products
  • Thought some of the provided examples of poor usability were really system bugs, indicating differences in the definitions of usability among presenters and industry representatives
  • Were concerned that usability standards could be so granular that they would specify or even mandate where particular elements would be placed on EHR screens across vendors

Obviously, more work is needed on developing a shared understanding between industry and others about the definitions, value and intentions of improving the user experience for EHRs. The tincture of time, education about usability and national leadership will be needed to effect this critical change in thinking.

Proofed by Jack Yensen

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