Sarita Lehtivuori is an adventurous nurse and usability enthusiast in the IT world.
There is nothing more frustrating for social and health professionals than struggling with unmanageable health IT systems. Having previously worked as a nurse/caregiver, the same complaints resonated in coffee rooms and hallway conversations, regardless of the EHR being used: the program is cumbersome, functions cannot be found or are many clicks away, the program is too slow, or the user cannot correct necessary information. EHR systems have not traditionally been very intuitive to use, their instructions for use are generally long, and even if the material is important, employees are rarely given the time for proper training in their use. This exposes employees to incorrect or unnecessarily complex solutions when navigating the UI. The systems also generally have lots of bugs. Traditional or legacy EHR systems have been in use for a long time and their development is challenging, not only because of the so-called legacy “solutions”, but also because many national laws, regulations, and requirements affect the consistency, interoperability, and privacy of records.
Together at a round table
Having worked in both nursing at different organizations as a user of different systems and as a specialist at a large EHR supplier in many roles from customer support to consultant, I saw successes and challenges related to the use and development of EHR systems from multiple different perspectives. However, the idea of confrontation is very old-fashioned. It is better to imagine a table as a round table of equal partners, where even the customer who needs healthcare services has a place. The customer needs help, support, care, listening, and involvement from clinicians. The customer, though, at the end of the day is not that interested in which system vendor his or her information is being processed on, as long as they are satisfied with the help they receive. Various electronic services are helping to get patients involved in their own care to an increasing extent, and it is important to take the customer’s perspective into account in their development work. From the point of view of a social and health professional, it is important to prioritize responding to the needs of the patient. Different information systems are only a tool to achieve these goals and should facilitate and speed up nursing work as well as ensure the integrity and continuity of important patient data. It is in the interests of the software supplier to produce high-quality and functional software that is suitable for a wide customer base, as well as to ensure smooth maintenance and development services while also sustaining cost efficiency. The development of EHR systems is a business just like the development of software is.
Based on my own observations, problems may arise, for example, when the user does not receive adequate guidance or training on how to use the system, if the system is difficult to use, or if its functions do not support the real user needs. Problems also arise if using the system consumes too much patient time. The main job of a social and health professional should not be the learning of complex software, but the system should be agile and intelligent, guaranteeing timely and appropriate care to the patient, ensuring continuity of care, and recording patient data, integrity, and security.
Factual information is usability’s friend
The flow of information and communication between the customer organization using the information system and the software vendor is important for both the software development and the correction of possible system errors. When a nurse or physician (i.e., an end user) encounters a problem with a patient information system that is not resolved by their organization’s administrator, a request is sent to the software vendor’s customer support. Because social and health professionals are not usually technical experts in software, the description of the problem may remain superficial from the point of view of the application expert and more information is often needed before a solution can be sought. I honestly admit that my own first request for support has sounded roughly like this: “Help, my *EHR vendor name* isn’t working!”. The administrator expertly inquired about a slightly more detailed description of the user’s problem and the matter was resolved. When software vendor customer support is required, an analytical and accurate description of the problem is essential. The application specialist works closely with the client organization administrator, but sometimes you will also need to contact the professional who reported the problem for more information. Because the working days of professionals are usually full of customer and patient contacts and accessibility is difficult, problem solving can be delayed. Sometimes needing a fair amount of back and forth through email between the application expert, the administrator, and the professional before the necessary information was carefully determined: who did, when did, what did, where did, how did, and what went wrong with it.
A modern software vendor recognizes the importance of high-quality design and conceptualization in creating an EHR system that is usable and truly meets all of the end user needs. It would be a good idea to involve social and health professionals that are using the system in the software development as early as possible. With the help of clinical experts, it is easier to design functions that support professionals in the right way and that are flexible to the varying and demanding needs of primary care, specialist care, and social care. It is good to make agile further development on top of a well-functioning infrastructure as operating methods develop and change. Various workshops, observations, and usability tests provide valuable information to the software vendor about the direction in which development should be taken. However, the challenge in these may be that the number of participants is small and often the participants come from the same organization. In this case, the experiences of individuals are highlighted and potentially different uses of the software by other users (not to mention different organizations) may go unnoticed. The end user may not be accustomed to describing their uses aloud and may have automated routines related to the use of the software that may go unnoticed by the observer. If more extensive data on the use of the software were automatically stored when using the software (without compromising the security of patient data), clear practices could be distinguished from this raw data as guidelines for software development and possibly outlined to help users use the software more smoothly.
How to melt the heart of even the most hardened “anti-EHR” users?
Since sweeping all existing EHR’s to non-existent and clean rooms with state-of-the-art technology and prioritizing usability above all else, is not a realistic option, what solutions are left for us that are hungry for usability to develop existing patient record systems? My own view is that the focus should first be on collecting data on the use of EHR systems extensively and systematically with automated tools and combining the collected information with the experiences shared by users in order to identify actual established uses and priority development needs. Based on the information gathered, user experience experts and clinical experts from software vendors/customer organizations would formulate solution proposals that would be weighed by software architects and developers in terms of technical feasibility before selecting a particular solution. In this way, a clear path to practical implementation could be determined, along which guidelines for further development. Following a well-laid-out path, the cost of software development would also be kept under control when time and resources were used efficiently and the number of possible remedies was reasonable.
I think the good and competitive patient information system of the future is an easy-to-use, intuitive, intelligent, and agile assistant that frees up professional time for a human encounter. A smart system would comprehensively collect feedback and data on its usage patterns to support high-quality further development (and problem solving). I believe that even a hardened professional who has matured into information systems would simply jump for joy in the coffee room and might even take a couple of gallop steps in the hallway when he gets such a system in his hands.