If there’s one thing we know about EHRs, users hate clicks. And for good reason. Clicking and scrolling historically have represented extra time, effort and evidence of not understanding an efficient workflow. Click reduction is often cited as the best way to improve electronic health record (EHR) usability. Our gut instinct tells us that we should do everything we can to reduce clicks.

Yes, unnecessary steps are annoying and should be removed. But we have to be careful that we don’t actually increase cognitive load, hinder decision making and reduce overall efficiency and satisfaction in our zeal to reduce clicks and scrolling. There is a great deal of research available that should guide the design, implementation and customization of EHR interfaces.

In the evidence-based practice of medicine, scientific evidence should also guide Health IT usability decisions. Some of these known facts that come from a solid foundation of research results include:

Processing fluency – When users encounter cognitive hurdles caused by poor EHR design, they are more likely to judge the task as more difficult and task performance suffers. So it is important to remove anything that interrupts processing fluency. For example, the date format “10/5/16” requires the user to translate the number 10 into October, whereas “Oct. 5, 2016” is faster for the user to process, and is more globally understandable. Removing these processing interruptions will increase overall satisfaction and performance

Readability – The more “readable” text is, the better your comprehension rates will be. Studies have shown that sentence length, contrast, font size and color all play a role in how easily a reader will be able to understand information. Follow best practices, and the user is less likely to experience eye strain, miss important information or waste valuable time.

Fear of emptiness – Also known as Horror Vaccui, is the idea that people have a natural urge to fill blank spaces. Ironically, the more we fill blank spaces with objects or information, the perceived value decreases.

Cognitive tax – When two or more perceptual or cognitive processes are in conflict, it requires additional processing to resolve the conflict, and the additional time and effort have a negative impact on performance. Decision-making research shows us that not only can more information be more cognitively taxing, but it can also lead to suboptimal decisions.

Data vs. Instinct – Which will win out in usability decisions?

The industry recognizes we need to improve EHR usability. Decisions about design and usability should not be based on instincts or “gut feel.” Designers should follow specific guidelines that they all too often ignore in favor of other considerations. For example, using brand colors for text and background on a web page might fit visual branding standards, but it could create a readability issue if the colors don’t have a good contrast ratio.

There are three main things we should do as an industry that will help advance usability:

1) Believe the science. We rely on scientific evidence to guide clinical decisions, we should adhere to the same standards for usability. Rely on data to understand the tradeoffs with every decision. For example, we can get more information on a screen to remove clicks and scrolling, but reducing the font size to do it will make reading slower, more difficult, and more error-prone.

2) Participate with and hold vendors accountable. EHR vendors need honest, consistent input. Work with them and point out trouble spots. Let them know when readability is compromised. Point out unnecessary clicks, but recognize that a narrow focus on clicks can mean exchanging one source of pain with another that could be worse for safety and satisfaction.

3) Be open minded. Some new interactions may not feel right or familiar at first, but if it’s based on good data it will help improve efficiency, effectiveness and satisfaction. When they’re based on research and best practices for user-centered design, you will likely find that they improve your overall experience with related tasks.

By embracing these principles, we can steer usability away from “gut feel” and make data-driven, evidence-based design decisions.

Editor’s Note: For more examples and references, Allscripts clients can access Ross Teague’s “Science of Usability” presentation on ClientConnect. Two additional useful references include Universal Principles of Design by William Lidwell, Kritina Holden, and Jill Butler; and Universal Methods of Design by Bella Martin and Bruce Hannington.

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About the author

Ross Teague, Ph.D., director of user experience research, leads the cross-functional team that provides user-experience (UX) and user-centered design (UCD) support for Allscripts. His team provides the research, design (conceptual and detailed) and evaluation necessary for the UX needs. Ross also manages the Allscripts effort to meet Meaningful Use UCD requirements and update of our development process to include UCD activities and measures. Prior to joining Allscripts, Ross was partner and director of research at Insight Product development, a design and strategy firm specializing in the planning and development of medical devices. Prior to Insight, Ross worked as a human factors psychologist in a business and design services group at Intel, helping to develop internet based products for companies outside of Intel. Ross holds a Ph.D. in Applied Cognitive Psychology and Human Factors.

4 COMMENTS on In defense of necessary clicks: The science behind usability

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Bennett Lauber says:

09/02/2016 at 7:45 am

Nice post on applying science to the usability of health IT.

I’ve spent my 20+ year career trying to explain how to apply the theories of science (mostly cognitive and social psychology) to the design and development of software. (google: “Jean Piaget and the usability of healthcare software” for an example)

Usability and User-centered design are based upon the concept of Human factors engineering–Engineering products to match the various factors associated with being human. The most obvious Human factors are those that are physical in nature, but Instead of designing a chair to better match your physical self, UX professionals use software human factors to help developers design software to match your thoughts and expectations.

If medical professionals can come to your website, EHR, or use your applications with considerable ease—when compared to, say your competition—they will likely make less errors, be quicker, and be happier. Hopefully making you and your company much more money, and saving lives in the process!

We need more articles like this written and more EHR vendors (product managers listen up!) to read them!

With the ubiquitous internet and mobile connected devices User eXperience is finally gaining some traction. Healthcare IT is at least 10 years behind enterprise IT, which in turn is about 5 years behind commercial software. Let’s do something!

Ross Teauge says:

09/02/2016 at 9:12 am

Thanks for your comment, Bennett. More awareness is definitely needed. Glad to hear that you are out there preaching the same message. Keep it up!

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Jacob Dixon says:

09/02/2016 at 2:56 pm

Really nice article Ross, happy to see it!

I like point #2 in advancing usability a lot in terms of a partnership in creating great software. I’m pretty certain you’d agree that ultimately it’s the EHR vendors responsibility to deliver usable software, and a collaborative partnership is a great way to move faster. Ultimately though, true accountability for usability will be driven by lowered costs of change and greater feature parity. If it’s cost-prohibitive to purchase (or switch to) the more usable systems, i worry the urgency to strengthen the partnerships you are talking about falls to far to the provider side. Wonder what your thoughts are on that?

Healthcare is behind other industries in terms of usable technology, because there haven’t traditionally been enough people like you in the vendor space. Thanks for taking a lead role in what comes next! :)

Jacob

    Ross Teauge says:

    09/06/2016 at 9:24 am

    Jacob, I think you might have given me the title of my next blog post (“EHR Usability: Whose responsibility is it?”)! It’s a great question. My instinct is to approach this from the perspective that we (vendors) can design a system that is usable and safe, but the longer I’m in this field I recognize that collaboration with health care organizations, clinicians, payers, and regulators isn’t only useful, but required to achieve these goals. This complex socio-technical system means, for example, that one stakeholder (e.g., an health organization) can make a usable product difficult to use by requiring a clinician to complete lots of tasks that someone else could do. I do agree that vendors must own this effort. One of the reasons for this blog post was to highlight how there is information that vendors should have about usability that needs to be held firm in the face of requests to do something less usable/safe by users, but it also applies to regulators and organizations. A partnership is important but vendors have to lead and highlight specifically where decisions and implementations will reduce efficiency, effectiveness, safety, and satisfaction.

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