Human Factors Can Assist with Appropriate Implementation of Health Information Technology

On February 17, 2009, President Obama signed into law the American Recovery and Reinvestment Act (ARRA) of 2009 (13.4 MB, .pdf).  Its’ stated purpose, among other things, is “to provide investments needed to increase economic efficiency by spurring technological advances in science and health” (p. 2).  The act consists of several provisions, including title XIII – Health Information Technology (a.k.a., “Health Information Technology for Economic and Clinical Health Act” [HITECH Act]).  According to the ARRA:

“‘health information technology’ means hardware, software, integrated technologies or related licenses, intellectual property, upgrades, or packaged solutions sold as services that are designed for or support the use by health care entities or patients for the electronic creation, maintenance, access, or exchange of health information.” (p. 115)

“‘qualified electronic health record’ means an electronic record of health-related information on an individual that-”(A) includes patient demographic and clinical health information, such as medical history and problem lists; and ”(B) has the capacity-”(i) to provide clinical decision support; ”(ii) to support physician order entry; ”(iii) to capture and query information relevant to health care quality; and ”(iv) to exchange electronic health information with, and integrate such information from other sources.” (p. 115)

“‘certified EHR technology’ means a qualified electronic health record that is certified pursuant to section 3001(c)(5) as meeting standards adopted under section 3004 that are applicable to the type of record involved (as determined by the Secretary, such as an ambulatory electronic health record for office-based physicians or an inpatient hospital electronic health record for hospitals).” (p. 114)

The ARRA authorizes $19 billion (Blumenthal, 2009) in funding between 2011 and 2015 to facilitate health information technology acquisition and implementation.  Of this amount, $17 billion is allocated for Medicare and Medicaid reimbursement incentives to physicians and hospitals “for adoption and meaningful use of certified EHR technology” (ARRA, 2009, p. 353).  Eligible physicians can receive up to $44,000 in incentive payments starting in 2011 (p. 354), while eligible hospitals will receive a base amount of $2,000,000 (p. 363).  The remaining $2 billion is allocated to Office of the National Coordinator (ONC) for Health Information Technology “to carry out title XIII of this Act” (p. 65).

Electronic health record systems, one type of health information technology, are a main focus of the HITECH Act.  Although, as of yet, there is no standardized definition for electronic health record systems (Jha, et al., 2006), some agreement has been reached on the core functionalities they should possess.  Specifically, eight categories (see Institute of Medicine (2003) for more detail) have been identified, including:

• health information & data;
• results management;
• order entry & management;
• decision support;
• electronic communication & connectivity;
• patient support;
• administrative processes; and
• reporting & population health management. (p. 7)

Moreover, the “core EHR system functionalities” should meet five criteria:

• improve patient safety;
• support the delivery of effective patient care;
• facilitate management of chronic conditions;
• improve efficiency; and
• feasibility of implementation (Institute of Medicine, 2003, pp. 5-6).

This sentiment is reflected in the U.S. Department of Health and Human Services Office of the National Coordinator for Health Information Technology homepage, where it states they can:

• improve health care quality;
• prevent medical errors;
• reduce health care costs;
• increase administrative efficiencies;
• decrease paperwork; and
• expand access to affordable care.

Although appropriately implemented EHR systems have the potential to increase the efficiency, quality, and safety of health care (Chaudhry, et al., 2006), while decreasing associated costs (Girosi, Meili, & Scoville, 2005), adoption in the U.S. is still very low (DesRoches, et al., 2008; Jha, et al., 2006).  In a recent survey of 3049 acute care general hospitals, it was determined that only “1.5% (95% confidence interval [CI], 1.1 to 2.0) of U.S. hospitals had a comprehensive electronic-records system implemented across all major clinical units and an additional 7.6% (95% CI, 6.8 to 8.1) had a basic system that included functionalities for physicians’ notes and nursing assessments in at least one clinical unit (Jha, et al., 2009, p. 1631).

Given the low adoption rates, it’s important to understand possible barriers that are preventing increased implementation.  Reported barriers (Blumenthal, 2009; Hoffman & Podgurski, 2008; Jha, et al., 2009; Wang, et al., 2005), include:

• lack of funding for purchase & maintenance;
• resistance from physicians & hospital staff;
• inadequate information technology staff; and
• hospital type (e.g., non-profit, for-profit, public, private, etc.) & size.

Moreover, besides barriers, there are also several potential negative consequences for improper implementation (Han, et al., 2005; Hoffman & Podgurski, 2008; Weimar, 2009), including:

• increased adverse & sentinel events;
• decreased patient & staff safety;
• increased litigation;
• increased physician & staff frustration; and
• privacy & security concerns of sensitive electronic information.

Although electronic health record systems have great potential, their implementation is often viewed as a mixed blessing.  The promises of new systems, software, and equipment are rarely realized.  Systems that looked good during the initial sale presentation are likely to create as many problems as they solve.  Even when systems undergo some level of evaluation, their implementation is all too often associated with surprises that require changes in work methods and processes.  To capitalize on the potential of electronic health record systems, it is incumbent on health care personnel to scrutinize needs, evaluate systems, assess impacts on personnel, establish work procedures, offer training, and provide technical support and maintenance.  With the number of available choices, barriers to implementations, negative consequences if improperly implemented, not to mention the limited time and resources health care personnel can devote to such an endeavor, they need a proven method to facilitate the selection and implementation process.  One way makes use of methods from the discipline of human factors and ergonomics.

What is Human Factors and Ergonomics?

Human factors and ergonomics is a unique scientific discipline that systematically applies the knowledge of human abilities and limitations to the design of systems with the goal of optimizing the interaction between people and other system elements to enhance safety, performance, and satisfaction.  In simpler terms, human factors focuses on designing the world to better accommodate people.

Human factors and ergonomics are relevant anywhere people work within systems, whether they are social or technical in nature – such as health care.  With regard to the procurement of electronic health record systems, it entails determining if the technology conforms to basic human factors principles and whether it will negatively influence the system (patients, hospital staff, other equipment, etc.) to which it will be integrated.   Increasing numbers of health care organizations are turning to human factors as a means of facilitating the process used to specify, evaluate, procure and implement new technology.

Benefits

The patient-centered systems approached used by human factors and ergonomics practitioners can provide health care organizations with a systematic process when purchasing and implementing electronic health record systems.  Using established human factors methods can:

• increase patient and staff safety;
• decrease numbers of adverse events;
• minimize the potential for new hazards to be introduced into the system;
• improve staff acceptance;
• increase work efficiency;
• better integrate with existing technology;
• decrease training time needed to reach competency; and
• minimize the need for modifications, “work arounds,” and/or shortcuts

Solutions

Human factors and ergonomics practitioners use a variety of methods when evaluating, designing, or procuring technology.  Two general human factors approaches can be used to analyze potential electronic health record systems prior to procurement and implementation: expert reviews and usability testing.

Expert Reviews

Expert reviews consist of a human factors and ergonomics expert assessing the electronic health record system to diagnose potential problems that might arise from the technology itself or after its integration in the health care organization’s system.  One of its strengths is that it allows the expert to “weed out” electronic health record systems that have poor usability.  Moreover, it seeks to identify if they conform to established human factors principles, including:

• assuring systems are easy and natural to use;
• maintaining consistency when possible;
• making things visible;
• providing appropriate feedback;
• minimizing reliance on users memory; and
• allowing for reversal of action.

Examples of expert reviews include heuristic evaluations, guideline reviews, and cognitive walkthroughs.

Usability Testing

Usability testing consists of having people from the target audience (i.e., physicians, nurses, staff, etc.) identify potential problems while performing typical tasks with the electronic health record system.  The steps required to complete a usability test include writing a test plan, designing the test, performing a dry run, recruiting users, conducting the test, analyzing the results, and determining the appropriate action to take.

Final Thoughts

Health care organizations are encouraged to incorporate both heuristic evaluations and usability tests to identify potential problems with the introduction of new electronic health records systems.  Heuristic evaluations are useful for identifying usability issues of electronic health records systems prior to integration.  However, heuristic evaluations cannot capture all the potential usability issues for new electronic health records systems or the level of staff acceptance and increased work efficiency.  Thus, it is necessary to also perform usability testing with health care personnel.  While both methods have their place, when used in tandem, they can have the greatest impact and success.  Using these methods also helps determine whether the electronic health records system effectively serves the goals of the organization (e.g., decreased medical errors, increased patient safety, etc.).  Finally, human factors & ergonomics methods are designed to help health care organizations maximize their ROI by increasing the positive and reducing the negative impact new electronic health records systems create.

Interested readers are encouraged to review the paper, “Assessing Devices from the User’s Perspective,” (4 MB, .pdf) that I co-authored with Curt Braun and was published in the September 2008 issue of Materials Management in Health Care, to learn more about this topic.

References

American Recovery and Reinvestment Act of 2009, Pub. L. No. 111-5, 123 Stat. 115 (2009).

Blumenthal, D. (2009).  Stimulating the adoption of health information technology.  The New England Journal of Medicine, 360, 1477-1479.

Chaudhry, B., Wang, J., Wu, S., Maglione, M., Mojica, W., Roth, E., Morton, S.C., & Shekelle, P.G. (2006).  Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care.  Annals of Internal Medicine, 144, 742-752.

DesRoches, C.M., Campbell, E.G., Rao, S.R., Donelan, K., Ferris, T.G., Jha, A., Kaushal, R., Levy, D.E., Rosenbaum, S., Shields, A.E., & Blumenthal, D. (2008).  Electronic health records in ambulatory care – A national survey of physicians.  The New England Journal of Medicine, 359, 50-60.

Girosi, F., Meili, R., & Scoville, R. (2005).  Extrapolating evidence of health information technology savings and costs. Santa Monica, CA: RAND Corporation.  Retrieved April 26, 2009, from: http://www.rand.org/pubs/monographs/2005/RAND_MG410.pdf

Han, Y.Y., Carcillo, J.A., Venkataraman, S.T., Clark, R.S.B., Watson, R.S., Nguyen, T.C., Bayir, H., & Orr, R.A. (2005).  Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.  Pediatrics, 116, 1506-1512.

Hoffman, S., & Podgurski, A. (2008).  Finding a cure: The case for regulation and oversight of electronic health record systems.  Harvard Journal of Law & Technology, 22, 103-165.

Institute of Medicine. (2003).  Key capabilities of an electronic health record system. Washington, DC: The National Academies Press.

Jha, A.K., DesRoches, C.M., Campbell, E.G., Donelan, K., Rao, S.R., Ferris, T.G., Shields, A., Rosenbaum, S., & Blumenthal, D. (2009).  Use of electronic health records in U.S. hospitals.  The New England Journal of Medicine, 360, 1628-1638.

Jha, A.K., Ferris, T.G., Donelan, K., DesRoches, C., Shields, A., Rosenbaum, S., & Blumenthal, D. (2006).  How common are electronic health records in the United States?  A summary of the evidence.  Health Affairs, 25, w496-w507.

Office of the National Coordinator for Health Information Technology – http://healthit.hhs.gov

Shaver, E.F., & Braun, C.C. (2008, September).  Assessing devices from the user’s perspective.  Materials Management in Health Care, 30-34.

Wang, B.B., Wan, T.T.H., Burke, D.E., Bazzoli, G.J., & Lin, B.Y.J. (2005).  Factors influencing health information adoption in American hospitals.  Health Care Management Review, 30, 44-51.

Weinmar, C. (2009, March-April).  Electronic health care advances, physician frustration grows.  Physician Executive Journal, 8-15.

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