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User-Centered Clinical Workflow Use Cases for EHR Satisfaction
User-centered clinical workflows can improve EHR satisfaction and help decrease health IT maintenance, training, and development expenses.
When the industry shifted from paper-based health records to EHRs about a decade ago, end-users were not at the helm of EHR development, which has impacted clinician burden. User-centered clinical workflows can help healthcare organizations improve EHR satisfaction by centering health IT functionality around the needs of clinicians.
Bill Hayes, MD, chief medical officer at health IT vendor CPSI, told EHRIntelligence in an interview that the problem with many of the early EHR platforms was that the vendors created them as transactional systems instead of workflow-driven systems.
He said that companies originally designed EHRs to measure encounters, financials, and document E&M codes, not to present longitudinal health data for care delivery and clinical decision support.
"The systems were all essentially designed in a way in which the applications dictated what the workflow was,” Hayes explained.
He said that to this day, EHRs often have a "huge navigator bar" of applications that serve individual purposes, such as order entry, dictation entry, and social history.
However, Hayes said that the industry is working towards creating user-centered clinical workflows that are supported by applications, rather than application-defined workflows.
According to HIMSS, user-centered design (UCD) describes a process in which the end-user influences the design throughout the development, implementation, and validation of a product or workflow.
UCD can help increase end-user satisfaction, while also delivering cost savings over the life cycle of a project by decreasing maintenance, training, support, and development expenses.
EHR Usability Testing
The day-to-day tasks of clinicians across the care continuum differ greatly. Following UCD processes can help ensure that health IT systems support the unique workflows of a wide range of providers.
For instance, a study published in Ophthalmology and Therapy found that UCD can boost EHR usability and decrease burnout for ophthalmologists.
HIMSS defines EHR usability as, “the effectiveness, efficiency and satisfaction with which specific users can achieve a specific set of tasks in a particular environment.”
Approximately 98 percent of hospitals have an EHR in place or plan to install one shortly and similar adoption rates occur in ophthalmology. However, ophthalmologists believe EHR usability leaves a lot to be desired and it often leads to increased clinician burnout and reduced time with patients.
Researchers concentrated on a UCD process to fix usability issues.
“The final product should suit the users, rather than making the users suit the product,” explained the study authors.
Researchers aimed to provide methodologies and usability analysis skills that clinicians can use to aid in EHR design and initiate conversations with EHR vendors during the development stages.
Using a literature search, researchers identified six methodologies and tools based on a UCD process and summative testing process to improve EHR usability:
- Shadowing: Researchers follow participants over a period and document user actions
- Autoethnography: The researcher becomes a user to see the thought process and documentation process
- Semi-structured interviews and questionnaires: Researchers provide users with open-ended questions which are analyzed by researchers
- Card sort and reverse card sort: Researchers identify common issues and ask participants to group topics into specific categories
- Retrospective think-aloud protocol: The participants carry out tasks silently and then communicate their thoughts after the process
- Wireframing, screenshot testing, and heat maps: Researchers develop a two-dimensional prototype of the EHR interface. The participants complete tasks through the prototype, which generates a visual map to see standard EHR interface clicks
Providing users with these methodologies and tools could educate clinicians from a usability standpoint to generate conversation with EHR vendors during the design process to boost clinician and patient satisfaction and safety.
“These tools should not be used in isolation but rather in conjunction with other EHR developmental processes such as utility analysis (whether the system provides features needed by the end user) and prototyping,” wrote the study authors.
“It is, however, beyond the scope of this paper to explore the full details of the EHR development process. The development and refinement of EHRs should be a continuous and iterative process, in which changes at one stage may require evaluation and changes at another stage.”
Overall, end-users should be involved in EHR usability testing, limiting potential future issues.
“This is very much like post marketing safety evaluations of technology and medications used in real-world clinical settings,” the study authors concluded. “With these tools that can be deployed in any clinical units away from resource-rich research centers, we hope that clinical information leads can work together with EHR vendors and various stakeholders to continuously improve the usability of EHRs.”
Integrating Mobile Applications
Most modern EHRs do not provide functionalities for collaborative, continuous plan updates and task management, according to a 2022 study published in Applied Clinical Informatics. Instead, much of clinicians’ minute-to-minute notations are performed outside of the EHR, often lost on paper.
Researchers leveraged a UCD strategy to implement a novel application to enhance clinical workflows at an academic hospital.
Rather than emulating pre-existing paper workflows in a digital format, the researchers sought to create a system, eventually dubbed Carelign, that leveraged digital technology and mobile devices.
“We attempted to match physicians' mental models more closely by designing Carelign to support updating the care plan more easily and frequently than is currently practical with daily progress notes,” the authors wrote. “Doing so then helps the care plan record keep pace with patients' evolving conditions.”
End-users reported that they were able to quickly learn to use the application. Clinicians also noted that the application improved their work experience and enhanced care coordination by increasing the safety and quality of their handoffs.
Clinicians could access Carelign from the EHR, computer workstations, and mobile devices. The study found that having mobile access to data increased the frequency with which teams accessed data on rounds while requiring less login time.
“Use of Carelign increased over the course of our study, even after the health system's implementation of a system-wide integrated EHR,” the study authors noted. “Clinical groups quickly began to envision new uses and even structure quality improvement projects around the application.”
The study authors emphasized that the design of the application benefited from constant user feedback. During pilot phases, end-users provided application feedback via an online survey. However, this was poorly utilized. The researchers moved the mechanism to an in-application tool, which proved a more streamlined method for users to give feedback.
Key factors for the success of this feedback mechanism were the inclusion of user contact information and application metadata, timely responses to user issues and suggestions, and incorporation of ideas into the application when appropriate.
Using UCD to Redesign Workflows
A study published in 2021 by Science Direct found that UCD helped improve EHR features, functionality, and workflow integration for cardiologists.
Between 2015 and 2017, 53 clinicians from eight cardiology practices (four academic and four private) participated in initial evaluations of their installed EHR.
Clinicians reported that their EHRs were poorly designed, scoring a mean of 47.1 on the System Usability Scale (SUS). They noted that EHRs impeded clinical workflow and prolonged their workday.
Researchers then assembled a multidisciplinary design team of clinicians and usability experts to create an EHR prototype.
The design team leveraged parallel convergent mixed methods using a complex clinical scenario and a simulated patient. Parallel convergent mixed methods combine qualitative and quantitative methods to facilitate a more complete understanding of problems, the authors explained.
Using data from the initial evaluation sessions, the design team deconstructed the clinical encounter into core concepts and clinical tasks. Then, the team reconstructed the clinical encounter to create a fully functional EHR prototype.
In 2019, 25 clinicians participated in final evaluations of their EHR vs the researcher’s EHR prototype. The study authors found no improvement in installed EHRs, with a mean SUS score of 48.1. The EHR prototype was assessed as significantly more usable, with a mean score of 77.8.
Integrating data collection into the workflow; linking diagnostics, therapeutics, and quality to specific problems; and pushing those data elements to clinicians improved EHR usability, the researchers said.
As healthcare organizations look to mitigate clinician burnout, ensuring that EHR systems support providers is crucial. UCD can help achieve this goal.