ONC Annual Meeting: Usability for better health IT safety

A panel discussed how to build safer systems for better care during the 2014 annual meeting of the Office of the National Coordinator for Health IT.

James Battles, PhD, senior service fellow for patient safety at the Agency for Healthcare Research and Quality’s Center for Quality Improvement and Patient Safety, relayed his recent experience visiting an emergency department (ED) with calf pain that was a suspected deep vein thrombosis. His primary care physician sent him to the ED and when Battles arrived, they were expecting him and were ready to perform a CT scan. He also was impressed with the follow-up contact he received from his providers. “I found myself in a system where everything went right but what about the poor guy who enters the usual healthcare system where things are not coordinated?”

Battles said he advocates for a shared mental model where everybody is on the same page at the same time. “How many patients are we putting at risk because we either haven’t created or have stovepiped our electronic information?” EHRs are other electronic tools can serve as the shared mental model. However, he said that EHRs can facilitate or enhance care or make matters worse.

There are two types of usability, said Terry Fairbanks, MD, MS, director of the National Center for Human Factors in Healthcare at the Medstar Institute for Innvoation: user interface design—referring to design of the system including screen designs, clicks and drags; and cognitive task support—referring to workflow design.

In paper records, Fairbanks said there are multiple visual cues to let someone know they might be in the wrong record. In EHRs, however, if the user selects the wrong record, almost nothing on subsequent screens looks different to alert an error. Both types of usability can improve the safety of systems. “Health IT hasn’t made us safer yet but it will make us dramatically safer than we are. Most of us only really have integrated usability in the last five years and that isn’t enough time to see it in the product yet.”

William Marella, MBA, director of patient safety reporting programs for the ECRI Institute, cited a study that found that the majority of reports about physician complaints about health IT “were not the things you typically think of as IT.” The issues actually were very analogous to paper records. About half the complaints were about putting incorrect data into the record or the correct information going into the wrong chart or the correct information going in the wrong field. “That has implications for the validity and accuracy of clinical decision support and, let’s face it, decision support is why we’re doing all of this. If we can’t get there because of the quality of the information going into the record, that’s a problem that has to be solved and it isn’t necessarily an IT problem.”

The panel took questions from the audience and one person asked what those currently shopping for an EHR system should look for. Battles said to find out how the system links with other components of the organization’s health delivery network. "If information cannot be shared across different systems, then it’s not going to be able to be used for a shared mental model.”

Fairbanks recommended buyers ask vendors how they design and determine what each user gets on his or her interface. He also said it’s important to know how much the vendor will partner to implement the system safely. “Organizations are asking for customization but that often ends up with the buyer using a different product in the end from a usability standpoint from what the vendor designed.”

Marella advised buyers to ask vendors what functions the system has to help monitor the safety of the system. “Not many have a prospective way of monitoring the health of the IT system as implemented— not just uptime but how users live with the system day in and day out.”