functionality and behavior of the software. At early
stages, users are generally asked to identify
workflows, evaluate information architecture,
language, and icons. Ideally, formative testing is
iterative, and done frequently within the software
development lifecycle. In contrast, summative
usability testing evaluates the user interface of
software in its current form. Different usability
evaluation techniques are used in summative testing.
For example, efficacy tests, or time task tests (the
time it takes a user to complete a certain task), and
user satisfaction can all be evaluated at this stage.
The goal of summative testing is to identify and rate
the usefulness of the interface, while providing
quantitative and qualitative feedback to the vendor
or internal engineering team on elements that need
to be fixed or enhanced. Some outcomes may be
issues of configuration, in which the implementation
team can work with to refine the parameters of
configuration, as opposed to a product change.
2.2 Why Is Usability Important?
Systems incorporating a user centered design, with
high levels of usability have been shown to support
clinician users in their workflow and help to increase
quality outcomes for patients (Garg, et al, 2005;
Chaudry, et al 2006; Bates, 2005). Conversely, a
lack of usability in the EHR has been associated
with unintended consequences, including harm to
patients (Campbell, et al, 2007).
EHR usability is a common complaint heard
among clinicians from hospital systems and
practices. HIMSS (2009) reports that usability is one
of the primary reasons, “possibly the most important
factor” hindering widespread adoption of EHRs
(http://www.himss.org/files/HIMSSorg/content/files/
himss_definingandtestingemrusability.pdf).
The HIMSS article describes that usability has a
strong, often direct relationship with clinical
productivity, error rate, user fatigue, and user
satisfaction, all important factors for EHR adoption.
Days spent for EHR training, while necessary, put
clinicians in a position to lose productivity.
Moreover, the months after a new HIT adoption,
clinicians need to adapt to the new tools and
workflow.
2.3 Market Demand
Despite the challenges of working with new EHR
systems that have improvements to be made in
usability, the “meaningful use” financial incentives
in the U.S. have kept the market demand high for
implementing an EHR system. In 2013, nearly six
in ten (59%) non-federal acute care hospitals had
adopted at least a basic EHR system with clinician
notes. (Charles, et al, 2014). This represents a 5-fold
increase in EHR adoption among U.S. hospitals
from 2008- 2013. Moreover, Charles and colleagues
(2014) report that 93% of hospitals possessed a
certified EHR technology, increasing 29% from
2011. Office based providers are also quickly
adopting EHR systems. A 2014 National Center for
Health Statistics report indicates that in the U.S. in
2013 over 78% of office based physicians used any
type of EHR system (Hsiao and Chung, 2014). This
statistic is up 18% from 2001. Further, the report
indicates that 69% of office based physicians plan to
participate in meaningful use incentives. This rapid
acceleration of EHR adoption in hospital systems
and physician offices puts a strain on end users,
implementers, and vendors to increase EHR
usability. At worst, the delay for EHR usability
enables increased medical error and unintended
consequences for patient outcomes. At best, as EHR
usability lags behind, so does the opportunity to
promote the end user experience, enabling the EHR
to be a catalyst for improved patient care and
wellness. We need to find better strategies for
usability to make it into the built EHR system.
2.4 Influence of the Organization
As we discuss the challenges to incorporating
usability into the EHR systems, in a fast-paced high
market-demand environment, it is important to
provide a context into which the systems will be
implemented and utilized. According the U.S.
government’s website “HealthIT.gov” (www.
healthit.gov), Peter Drucker, called health care
workplaces "the most complex human organiza-
tion[s] ever devised." Interactions between the
complex environments of health care workplaces
and increasingly complex EHRs can result in subtle
unintended consequences of EHR implementation.
The interactions between the EHR and the work
environment or between the EHR and the technical
and physical infrastructure can result in problematic
consequences, but not necessarily from any product
malfunction. The flow of interactions between the
HIT and the healthcare organization’s sociotechnical
system—its workflows, culture, social interactions,
and technologies can result in unintended and
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