The national debate on the usability of electronic health records (EHRs) for pediatric care has matured. There now is an established definition of usability, associated measures and validation methods for formal testing in a laboratory prior to use with patients.
The International Organization for Standardization defines usability as “the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use.” It is important to take into account the unique risks when caring for pediatric populations and tailor EHRs for the population, as suggested in a National Institute of Standards and Technology (NIST) report and an AAP technical report.
The NIST report makes a definitive link based on empirical data between usability and patient safety when clinically relevant information is not available, documentation is inadequate, and information is inaccurate or irretrievable. The report focused on the following issues, which can have potentially higher risk in pediatric patients due to design flaws: patient identification, medications, alerts, growth charts, vaccines, laboratory findings, newborn issues, privacy and radiology.
Human factors engineering
Smartphones are considered to have high usability, meaning they are optimized so that users do not need training to accomplish tasks.
Unlike smartphones and other consumer products, however, there are potentially high consequences for patient safety when an EHR system is used in a complex environment with highly trained and specialized users. Therefore, when designing EHR software, it is important to assume users will make mistakes when interacting with the system. The bottom line is that human factors engineering — designing systems, products and services to make them easier, safer and more effective for human use — must be used in any system where both intended and unintended actions can be dangerous if users learn as they go.
Functional requirements for pediatric care
To protect pediatric patients, the usefulness of EHRs also needs to be improved. Usefulness typically is characterized by functional requirements, and how these are implemented usually impacts usability of the interface.
A functional requirement for a car is a horn, which impacts the usefulness of the car. If the horn is in the glove compartment, then it has poor usability. Therefore, it could be required that every car has a horn in the center of the steering wheel that makes a noise within a particular range of decibels when activated and that typical representatives of pedestrian populations can identify the sound reliably as a “honk” from a specified distance away with background noise.
Similarly, it is reasonable to expect that there are functional requirements for EHRs such as a growth chart. However, the growth chart may not be represented in a standard format (Centers for Disease Prevention and Control/World Health Organization) with height and weight on the same graph or requires 10 clicks to access every time. Many more functional requirements for pediatric care are detailed in the NIST report.
When prioritizing the functional requirements that most impact patient safety with EHRs, a rule of thumb is to identify when the most fundamental aspects of providing clinical care could be compromised. For example, could the diagnosis be missed or delayed because critical information could not be found in historical notes due to the lack of a short summary of accurate, relevant, synthesized information about a patient?
Measuring success
One strategy for assessing success is to observe physicians using the EHR and confirm that they are not using “workarounds” and are accomplishing challenging tasks efficiently. For example, representative end-users might be using paper-based forms because EHR documentation is useful only for meeting billing requirements.
Overall, the need for verification and validation of useful and usable EHR systems to support pediatric care and health exchange systems will only increase. Both formative and summative usability testing will be critical. The more that pediatricians are aware of usability and usefulness, the more they can work with EHR vendors to achieve improvements.
Dr. Brick is a member of the AAP Council on Clinical Information Technology. Emily Patterson, Ph.D., associate professor at The Ohio State University School of Health and Rehabilitation Sciences in the College of Medicine, contributed to this article.
