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Reducing clinician burden with user-centered design

November 2019

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In This IssueA human factors approach considers how humans interact with technology and seeks to improve HIT usability. Clinicians and human factors scientists alike recognize how taking this approach to software development can improve patient care.

In this issue of Next Now, we explore the latest thinking in HIT software usability, take a look at what experts in the field have to say about the impact of human factors, and outline how Allscripts is examining its approach to the challenges usability presents.

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Tomorrow’s ideas, today.

4Reducing clinician burden with user-centered designHealthcare organizations seeking to improve clinician satisfaction need healthcare IT focused on purposeful, user-centered design.

By Ross Teague, Ph.D.

10A conversation with Raj Ratwani: Adapting the EHR for humansAllscripts sat down recently with Dr. Raj Ratwani, director of the MedStar Health National Center for Human Factors in Healthcare, which is part of the MedStar Institute for Innovation. Read an excerpt of the conversation with Allscripts Usability Director Ross Teague, Ph.D., and Allscripts Patient Safety expert Geoff Caplea, M.D.

6The relationship between usability and clinician burdenHealthcare organizations today face many challenges, from improving patient outcomes with limited resources to succeeding in a time of changing regulatory requirements. Healthcare organizations are also struggling to improve clinician satisfaction, and one of the largest factors affecting clinician satisfaction is health IT usability.

Ross Teague, Ph.D.

8What’s a human factors approach?Learn how to ground yourself and your teams in a sound human factors process, a sound user design process. As a user yourself or someone who works with users, keep working to raise the standard.

Dr. Janey Barnes, Founder of User View

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Reducing clinician burden with user-centered designRoss Teague, Ph.D.

Healthcare organizations seeking to improve clinician satisfaction need healthcare IT focused on purposeful, user-centered design. Some 86% of acute care

organizations and 67% of ambulatory care organizations cite usability as their biggest complaint.

The impact of poor usability is a major concern because it contributes so significantly to clinician burden.

The infographic on the opposite page illustrates alarming statistics that demonstrate the scope of the issue and call for immediate intervention.

Clinicians shouldn’t have to adapt to their tools to maintain desired outcomes. A focus on usability can enable users to

meet specified goals effectively. A proven user-centered design process helps deliver the right product to meet user needs.

Allscripts follows a rigorous user-centered design process, which enables us to understand the key concerns clinician users have, create innovative solutions and measure the results.

A rigorous user-centered process asks, “What would make this the most helpful for the user?” The answer fuels innovation and goes beyond delivering merely a usable solution, but one that actively helps the user.

To understand how Allscripts is improving usability across our solutions, see our whitepaper, “Reducing clinician burden with user-centered design.”

Clinician Well-Being

PersonalFactors

Skills &Abilities

Health CareResponsibilities

Learning/PracticeEnvironment

PatientWell-Being

OrganizationalFactors

Rules &Regulations

Society &Culture

Clin

ician

-Patient Relationship

This is a model of external and individual factors from the National Academy of Medicine (NAM)Action Collaborative on Clinician Well-Being and Resilience.

Factors affecting clinician well-being and resilience

IndividualFactors

ExternalFactors

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24%

+50% 39%

ICU nurses tested positive for symptoms

of post-traumatic stress disorder

2x suicide ratevs. that of the general

population

Physicians leaving practice early

in significant numbers

U.S. physicians report symptoms

of burnout

$500K-$1Mcost of replacing a

physician

physicians experience depression

Significantly higher than that of the general population (7%)

To understand how Allscripts is improving usability across our solutions, see our white paper, “Reducing clinician burden with user-centered design.”

Healthcare organizations can benefit with a healthcare IT focus on purposeful, user-centered design. Allscripts is focused on creating solutions that guide, warn, suggest, orient and assist users in a variety of ways—all focused on helping them meet their goals.

Reducing clinician burden with user-centered designHealthcare organizations are struggling to improve clinician satisfaction, and one of the largest factors affecting clinician satisfaction is health IT usability. The impact of poor usability is concerning, because it is a major contributor to clinician burnout.

Though clinician burnout is not a new issue, immediate intervention is necessary after viewing these alarming statistics:

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The relationship between usability and clinician burdenRoss Teague, Ph.D.

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Healthcare organizations today face many challenges, from improving patient outcomes with limited

resources to succeeding in a time of changing regulatory requirements.

Healthcare organizations are also struggling to improve clinician satisfaction, and one of the largest factors affecting clinician satisfaction is health IT usability.

Usability is a challenge across the board, with 86% of acute organizations citing usability as their biggest complaint, and 67% of ambulatory organizations citing usability as their biggest complaint.

The impact of poor usability is concerning because it is a major contributor to clinician burnout.

What is clinician burnout? Clinician burnout is a long-term stress reaction characterized by emotional exhaustion, depersonalization (cynicism) and loss of work fulfillment.

Clinician burnout is a critical concern, because it has been linked to serious consequences which impact clinicians, patients and the entire U.S. healthcare system.

Examples include reduced job performance, decreased patient engagement, poor quality and safety of care, increased healthcare costs and inferior health outcomes.

Several alarming statistics illustrate the severity of the problem, and highlight the need for immediate intervention:

• More than 50% of U.S. physicians report symptoms of burnout.

• The physician depression rate is significantly higher than that of the general population (39% vs. 7%).

• The physician suicide rate is 2x higher than that of the general population.

• Significant numbers of physicians are leaving practice early.

• The cost of replacing a physician is $500,000 to $1,000,000.

Clinician burnout is a systemwide problem with numerous external and individual factors. External factors, or the system attributes over which clinicians have limited control and within which they must work and adapt, include society and culture, rules and regulations, organizational factors, the learning and/or practice environment (which includes health IT usability) and healthcare responsibilities. Individual factors are the factors which are unique to clinicians, and over which they have more control.

Research suggests that external factors carry more weight in contributing to burnout and that interventions should focus more on the external system factors, to reduce burnout and promote well-being.

To understand how Allscripts is improving usability across our solutions, see our Whitepaper, “Reducing clinician burden with user-centered design.”

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What’s a human factors approach?Dr. Janey Barnes, Founder of User View

From decades of working with human factors and EHR design, I have one story that particularly

stands out for me.

I visited a small doctor’s practice, part of a larger system whose IT vendor had tried to address clinician usability issues for months. The vendor’s leaders had gone onsite in the past, sat in the conference room with the clinicians and listened to their problems and concerns. When they weren’t resolved, my team and I went to observe the clinicians at their day-to-day work.

The doctor, sitting at his computer with the nurse and physician’s assistant, was complaining he couldn’t pull up lab values, and he couldn’t practice medicine without them.

I knew from the system that he should be able to get his lab values. It turned out the doctor’s web browser was so out of

date that he in fact couldn’t access the lab values, nor many other features.

This was a simple fix, made in one day.

Most user experience problems aren’t solved by sitting around a conference table. They’re solved by engaging with the people involved and the work they do.

As the founder of a human factors and design company, I try to understand exactly how my customers use their systems, what challenges they’re facing and what they need.

When we discuss human factors as a topic, we’re discussing helping health IT teams make their systems truly work for humans. This involves improving the usability of their product, meaning real, individual humans can understand them.

Usability refers to the effectiveness, efficiency and satisfaction of a user being able to complete a particular task, in their particular environment, with the tools they’re given. This is a small slice within that individual’s user experience. Each of these levels presents opportunities to improve patient safety and clinician experience overall.

Many healthcare organizations have their own customized health IT, configured into EHRs. They have the best access to knowledge of what their clinicians need, what their resources and the capabilities of their homegrown applications and tools. Working with IT vendors, clinicians

Allscripts Podcast, Episode 1

What are Human Factors?

Defining human factors, usability and user experience; responding to US patient safety and usability standards today; how the FDA is an example for raising the bar for EHRs.

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and leaders at these organizations can develop a system that accommodates their own unique human factors.

This can be easier said than done. Focusing on human factors and achieving truly user centered design in an IT system for healthcare is complex in a way it wouldn’t be for other industries. The very different operations of different providers—large hospitals, small hospitals, city hospitals, rural hospitals, ambulatory practices, mental health facilities—makes this more complicated.

That’s why it’s key to understand, as a provider or a vendor, that every implementation and the user group it serves is different. While there are patterns or behavior and clinical workflow we can draw on, we must be aware that a doctor’s not a doctor wherever you find a doctor, so to speak, and a practice isn’t a practice for every one you walk in.

In a sound and proven human factors engineering program, knowing the users and knowing what the environment is like where the product is going to be used is crucial because it’s so complex in health IT.

My advice to address this pretty simple. Ground yourself and your teams in a sound human factors process, a sound user design process. As a user yourself or someone who works with them, keep working to raise the standard.

Every time you do an activity, or observe a user doing one, evaluate the worth of that activity. Ask if you learned something, and how you can translate that learning into the design, development, and implementation of a system. Again, you can do this as a provider, clinician or vendor, and communicate what you find. Breaking down these silos in the health

IT ecosystem is essential to building user centered systems.

In the podcast episodes I recorded with Allscripts, we had human factors, user experience and patient safety experts all talking to each other, sharing good ideas. The same conversation could occur with users and people from a healthcare delivery system, sharing their own ideas and the reality of their experience.

For the doctor at the small practice who couldn’t get his lab values, this conversation would have solved his problem before it began. In that case, we did solve it by taking a real human focus, working together to see what he saw, in the environment he worked in. That’s the approach we all need to continue to take.

Allscripts Podcast, Episode 2

Making Systems Work for Humans

The unique challenges of healthcare technology; how HIT partners can engage with users to discover their true needs; and how the right system supports patient safety and relieves clinician burden.

Allscripts Podcast, Episode 3

At Every Step, Factor in Humans

How health IT platforms compare to those in other fields; how hands-on training makes a difference; and how a human-centered approach at every step, from implementation to daily use, creates systems that fit each unique organization.

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A conversation with Raj Ratwani: Adapting the EHR for humansEDITOR’S NOTE: Allscripts sat down recently with Dr. Raj Ratwani, director of the MedStar Health National Center for Human Factors in Healthcare, which is part of the MedStar Institute for Innovation. He is also an assistant professor of emergency medicine at the Georgetown University School of Medicine. His career is focused on improving the safety, efficiency and quality of care through the application of human factors and applied psychology. He holds a master’s degree and Ph.D. in psychology, with a focus on human factors. The following is an excerpt of the conversation with Allscripts usability director Ross Teague, Ph.D., and Geoff Caplea, M.D.

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TEAGUE: You’ve been outspoken about the need for EHR vendors to be more open about product safety and usability. How’s this going, has this been embraced, and if it would be embraced, what would that look like?

RATWANI: It’s challenging, as you might expect. In any industry it’s hard to get industry players to share things they’re uncomfortable talking about. Safety of anybody’s product is one of those key things. Overall, it’s been really difficult. Take one step back and think about why this is so important, why am I pushing on this so much.

Two reasons:

An increasing number of patients are harmed because of or at least with contributions from EHRs. If you look at legal claims data, 1.6-1.8% of legal claims have a relationship to EHRs. Several years ago, that was near zero, which is what you’d expect given that we’ve seen this very recently, with widespread adoption, so that it a little reason for concern

Then, from research our team has conducted, as well as others, we see there are several safety issues, and I think an increasing number are tied back to the EHR. There’s a concern that there are growing contributions of EHRs to impacting safety.

CAPLEA: We all agree that EHR vendors have to do their part. But what do you recommend for healthcare provider organizations to ensure usability, safety and satisfaction?

RATWANI: Some examples of what providers could do:

Really engaging in training, ensuring their staff and associates are trained to use the EHR. For some human factors folks, the word “training” is a bad word. They think systems should be so intuitive that training’s not required.

The fact is the systems are so complex training should be required. Not just general training, but very tailored and specific training, provided to clinicians, in particular, working through scenarios they’ll face and training that resembles what they’d do in actual clinical situations.

Also, maintaining that training. Provider organizations sometimes look at health tech and EHRs as a one-time investment and purchase. The fact, this requires ongoing maintenance, retraining, situations change, upgrades happen, features change.

TEAGUE: Why are we still having this conversation? Why are we still talking about usability of EHRs? Why is usability and clinician burden such a challenge?

RATWANI: The way we’ve done EHR adoption since the HITECH Act of 2009 has been incredibly complex, and we’ve looked at other industries to find a parallel. There’s really not one.

People compare to finance, aviation, ground transportation, nuclear energy, and there are a couple similarities. But I can’t find a single industry where there was a massive $40 billion program to incentivize adoption of tech as was done in

healthcare. Also, these systems are not just about providing care, they’re about billing and lots of different things. And so, I think we have to recognize how complex this space is.

Moving forward, what we have to do is separate billing functionality and needs in these systems to what’s needed for actual clinical care.

TEAGUE: What needs to happen to enable that?

RATWANI: We’re going to need a pretty disruptive change for this to happen. First, we’ll need a dramatic policy shift. Because one reason we have this combination of EHRs for clinical care, but also billing, is related to lots of different stakeholders that are pushing that, and now all those policies are making it so that has to be the case.

We don’t have a history of that disruption, and we’ll have to figure something out until that disruption arises, so it’s unpredictable. Very unpredictable.

CAPLEA: To leverage your background in clinical psychology, I want to talk about clinician burden. So much of this comes down to a conversation about clicks, time on task. Obviously, those are burdensome, but one thing we’ve been trying to talk about is the concept of cognitive burden, a mismatch of product or action with people’s cognition. Can you talk about your take on the cognitive burden of using an EHR?

RATWANI: To me this means the way that we think about doing something—the way we’re used to doing something—isn’t supported by the piece of technology in front of us.

Therefore, the way we would routinely interact with a system, we can’t do that anymore. We have to use more cognitive resources to think about the action we take in this system.

What clinicians are facing is that for several routine actions on the EHR, they have to think deeply about each one of those interactions, think about exactly what they’re clicking on, what that means, which introduces burden that we didn’t have before. It takes away from what they’re doing, interacting with patients.

It’s that kind of issue we’re facing, but I do think it’s getting better.

Podcast Series: Adapting the EHR for Humans

How the EHR is linked to safety and clinical outcomes; aligning cognition to EHR use; receiving and implementing input from clinicians, partners and leaders. A three-part interview with Raj Ratwani.

Patient Safety is Everyone’s Business – Adapting the EHR for Humans with Raj Ratwani, part 1

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The story of possible.When you’re dealing with people on the best or worst days of their lives, you can’t overprepare. You are tasked with offsetting the needs of a business full of financial and competitive pressures, without compromising the care of a human life. That’s why we offer flexible solutions rather than abiding by the oh-so-common “one-size-fits-all” mentality—not just for patients and families but for the doctors and staff taking care of them. With abundant humility, we offer that our role is a noble one. We use technology to help you provide care, and we believe the hardest part of healthcare shouldn’t be gathering the information to provide it properly. We enable amazing teams that beat cancer, deliver babies, and make people walk again. We are the support system with lifelong consequences. It’s a massive balancing act: between integration, privacy, and practicality. And it all needs to be handled with grace and understanding, and be permeated with hope.

When you change what is possible, you change everything.