Human Factors and Health Information Technology: Current Challenges and Future Directions

Summary

Objectives: Recent federal mandates and incentives have spurred the rapid growth, development and adoption of health information technology (HIT). While providing significant benefits for better data integration, organization, and availability, recent reports have raised questions regarding their potential to cause medication errors, decreased clinician performance, and lowered efficiency. The goal of this survey article is to (a) examine the theoretical and foundational models of human factors and ergonomics (HFE) that are being advocated for achieving patient safety and quality, and their use in the evaluation of health-care systems; (b) and the potential for macroergonomic HFE approaches within the context of current research in biomedical informatics.

Methods: We reviewed literature (2007-2013) on the use of HFE approaches in healthcare settings, from databases such as Pubmed, CINAHL, and Cochran.

Results: Based on the review, we discuss the systems-oriented models, their use in the evaluation of HIT, and examples of their use in the evaluation of EHR systems, clinical workflow processes, and medication errors. We also discuss the opportunities for better integrating HFE methods within biomedical informatics research and its potential advantages.

Conclusions: The use of HFE methods is still in its infancy - better integration of HFE within the design lifecycle, and quality improvement efforts can further the ability of informatics researchers to address the key concerns regarding the complexity in clinical settings and develop HIT solutions that are designed within the social fabric of the considered setting.

Keywords

Systems-oriented approach - macroergonomics - socio-technical frameworks - patient safety - human factors

• References

• 1 Institute of Medicine (IOM).. Health IT and Patient Safety: Building Safer Systems for Better Care. Washington, DC: Institute of Medicine; 2011
• 2 Linder JA, Ma J, Bates DW, Middleton B, Stafford RS. Electronic Health Record Use and the Quality of Ambulatory Care in the United States. Arch Intern Med 2007; 167 (13) 1400-5.
• 3 Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE. et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005; Mar 9 293 (10) 1197-203.
• 4 Congressional Budget Office.. Evidence on the Costs and Benefits of Health Information Technology. The Congress of the United States. 2008
• 5 Zhang J, Walji MF. TURF: toward a unified framework of EHR usability. J Biomed Inform 2011; Dec 44 (06) 1056-67.
• 6 Weinger MB, Wiklund ME, Gardner-Bonneau DJ. Handbook of human factors in medical device design. US: CRC Press; 2010
• 7 Zhang J, Johnson TR, Patel VL, Paige DL, Kubose T. Using usability heuristics to evaluate patient safety of medical devices. J Biomed Inform 2003; 36 (01) 23-30.
• 8 Malhotra S, Jordan D, Shortliffe E, Patel VL. Workflow modeling in critical care: piecing together your own puzzle. J Biomed Inform 2007; Apr 40 (02) 81-92.
• 9 Patel VL, Kannampallil TG. Cognitive Approaches to Clinical Data Management for Decision Support: Is It Old Wine in New Bottle?. In: Holzinger A, Simonic K-M. editors. Information Quality in e-Health. Berlin, Heidelberg: Springer; 2011. p. 1-13.
• 10 Patel VL, Kaufman DR, Kannampallil T. Diagnostic Reasoning and Decision Making in the Context of Health Information Technology. Reviews of Human Factors and Ergonomics 2013; 8: 149-90.
• 11 Institute of Medicine (IOM).. Patient safety: achieving a new standard for care. National Academies Press; 2003
• 12 Carayon P, Wetterneck TB, Rivera-Rodriguez AJ, Hundt AS, Hoonakker P, Holden RJ. et al. Human factors systems approach to healthcare quality and patient safety. Appl Ergon 2014; 45 (01) 14-25.
• 13 Karsh BT, Holden RJ, Alper SJ, Or CK. A human factors engineering paradigm for patient safety: designing to support the performance of the healthcare professional. Qual Saf Health Care 2006; Dec 15 Suppl 1: i59-65.
• 14 Salvendy G. Handbook of Human Factors and Ergonomics. Second Edition. New York: John Wiley & Sons; 1997
• 15 Wickens C, Lee J, Liu Y, Becker SG. An Introduction to Human Factors Engineering. Second Edition. Upper Saddle River, NJ: Pearson Prentice Hall; 2004
• 16 Walton M, Woodward H, Van Staalduinen S, Lemer C, Greaves F, Noble D. et al. The WHO patient safety curriculum guide for medical schools. Qual Saf Health Care 2010; 19: 542-6.
• 17 Congress of the United States.. American Recovery and Reinvestment Act (ARRA) 2009. Available from: http://www.gpo.gov/fdsys/pkg/BILLS-111hr1enr/pdf/BILLS-111hr1enr.pdf.
• 18 Ash JS, Stavri PZ, Kuperman GJ. A consensus statement on considerations for a successful CPOE implementation. J Am Med Inform Assoc 2003; May-Jun 10 (03) 229-34. .
• 19 Berg M. Patient care information systems and health care work: a sociotechnical approach. Int J Med Inform 1999; 55 (02) 87-101.
• 20 Carayon P, Karsh BT, Gurses AP, Holden RJ, Hoonakker P, Schoofs Hundt A. et al. Macro-ergonomics in Health Care Quality and Patient Safety. Reviews of Human Factors and Ergonomics 2013; 8 (01) 4-54.
• 21 Gurses AP, Ozok AA, Pronovost PJ. Time to accelerate integration of human factors and ergonomics in patient safety. BMJ Qual Saf 2012; Apr 21 (04) 347-51.
• 22 Gosbee J. Human factors engineering and patient safety. Qual Saf Health Care 2002; 11: 352-4.
• 23 Norris BJ. Human factors and safe patient care. J Nurs Manag. 2009; 17 (02) 203-11.
• 24 Chapanis A, Safrin MA. Of misses and medicines. J Chronic Dis 1960; Oct 12: 403-8.
• 25 Safren MA, Chapanis A. A critical incident study of hospital medication errors. Hospitals 1960; May 1 34: 32-4 passim..
• 26 Catchpole K. Spreading human factors expertise in healthcare: untangling the knots in people and systems. BMJ Qual Saf 2013; 10: 793-7.
• 27 Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective team-work and communication in providing safe care. Qual Saf Health Care 2004; Oct 13 Suppl 1: i85-90.
• 28 Gaba DM. Have we gone too far in translating ideas from aviation to patient safety?. No. BMJ. 2011 (342) c7310
• 29 Rogers J. Have we gone too far in translating ideas from aviation to patient safety?. Yes. BMJ. 2011 (342) c7309.
• 30 Jarrett D. Cockpit engineering. Farnham: Ashgate Publishing; 2005
• 31 Morrow D, Lee A, Rodvold M. Analysis of problems in routine controller-pilot communication. The Int J Aviat Psychol. 1993; (03) 4.
• 32 O’Leary M, Chappell SL. Confidential incident reporting systems create vital awareness of safety problems. ICAO J 1996; 51 (08) 11-3 27.
• 33 Haller G, Garnerin P, Morales MA, Pfister R, Berner M, Irion O. et al. Effect of crew resource management training in a multidisciplinary obstetrical setting. Int J Qual Health Care 2008; Aug 20 (04) 254-63. .
• 34 McCulloch P, Mishra A, Handa A, Dale T, Hirst G, Catchpole K. The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre. Qual Saf Health Care 2009; Apr 18 (02) 109-15.
• 35 Taylor CR, Hepworth JT, Buerhaus PI, Dittus R, Speroff T. Effect of crew resource management on diabetes care and patient outcomes in an inner-city primary care clinic. Qual Saf Health Care 2007; Aug 16 (04) 244-7.
• 36 Catchpole KR, Dale TJ, Hirst DG, Smith JP, Giddings TA. A multicenter trial of aviation-style training for surgical teams. J Patient Saf 2010; Sep 6 (03) 180-6.
• 37 McCulloch P, Rathbone J, Catchpole K. Interventions to improve teamwork and communications among healthcare staff. Br J Surg 2011; Apr 98 (04) 469-79.
• 38 Durso F, Drews FA. Healthcare, Aviation, and Ecosystems – A socio-natural systems perspective. Curr Dir Psychol Sci 2010; 19: 71-5.
• 39 Carayon P, Xie A, Kianfar S. Human factors and ergonomics as a patient safety practice. BMJ Qual Saf 2014; 23 (03) 196-205.
• 40 Carayon P, Schoofs Hundt A, Karsh BT, Gurses AP, Alvarado CJ, Smith M. et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care 2006; Dec 15 Suppl 1: i50-8.
• 41 Carayon P, Smith MJ. Work organization and ergonomics. Appl Ergon 2000; 31 (06) 649-62.
• 42 Donabedian A. The quality of medical care. Science 1978; May 26 200 4344 856-64.
• 43 Holden RJ, Rivera-Rodriguez AJ, Faye H, Scanlon MC, Karsh BT. Automation and adaptation: Nurses’ problem-solving behavior following the implementation of bar coded medication administration technology. Cog Technol Work 2013; 15 (03) 283-96.
• 44 Faye H, Rivera-Rodriguez AJ, Karsh BT, Hundt AS, Baker C, Carayon P. Involving intensive care unit nurses in a proactive risk assessment of the medication management process. Jt Comm J Qual Patient Saf 2010; 36: 376-84.
• 45 Wetterneck TB, Walker JM, Blosky MA, Cartmill RS, Hoonakker P, Johnson MA. et al. Factors contributing to an increase in duplicate medication order errors after CPOE implementation. J Am Med Inform Assoc 2011; Nov-Dec 18 (06) 774-82.
• 46 Carayon P, Alyousef B, Hoonakker P, Hundt AS, Cartmill R, Tomcavage J. et al. Challenges to care coordination posed by the use of multiple health IT applications. Work 2012; 41: 4468-73.
• 47 Gurses AP, Carayon P. Performance obstacles of intensive care nurses. Nurs Res 2007; MayJun 56 (03) 185-94.
• 48 Gurses AP, Carayon P. Exploring performance obstacles of intensive care nurses. Appl Ergon 2009; May 40 (03) 509-18. .
• 49 Holden RJ. Cognitive performance-altering effects of electronic medical records: An application of the human factors paradigm for patient safety. Cog Technol Work 2011; 13: 11-29.
• 50 Karsh BT, Weinger MB, Abbott PA, Wears RL. Health information technology: fallacies and sober realities. J Am Med Inform Assoc 2010; Nov-Dec 17 (06) 617-23.
• 51 Karsh BT, Wiegmann D, Wetterneck T, Carayon P. Communication and systems factors might still underlie surgical complications. Surgery 2009; 145 (06) 686-7.
• 52 Holden RJ, Karsh BT. A theoretical model of health information technology usage behavior with implications for patient safety. Behaviour & Information Technology 2009; 28 (01) 21-38.
• 53 Holden RJ, Karsh BT. A review of medical error reporting system design considerations and a proposed cross-level systems research framework. Hum Factors 2007; Apr 49 (02) 257-76.
• 54 Beuscart-Zephir MC, Elkin P, Pelayo S, Beuscart R. The human factors engineering approach to biomedical informatics projects: state of the art, results, benefits and challenges. Yearb Med Inform 2007; 109-27.
• 55 Beuscart-Zephir MC, Pelayo S, Bernonville S. Example of a Human Factors Engineering approach to a medication administration work system: potential impact on patient safety. Int J Med Inform 2010; Apr 79 (04) e43-57.
• 56 Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ 1998; 316 7138 1154.
• 57 Reason J. Human Error. Cambridge, UK: Cambridge University Press; 1990
• 58 Watterson PE. A critical review of the systems approach within patient safety research. Ergonomics 2009; 52 (10) 1185-95.
• 59 Russ AL, Fairbanks RJ, Karsh BT, Militello LG, Saleem JJ, Wears RL. The science of human factors: separating fact from fiction. BMJ Qual Saf 2013
• 60 Hutchins E. How cockpit remembers its speed. Cognitive Science. 1995; 19: 265-88.
• 61 Larkin JH, McDermott J, Simon HA, Simon DP. Expert and Novice Performance in Solving Physics Problems. Science 1980; 208: 1335-42.
• 62 Zhang J, Norman DA. Representations in Distributed Cognitive Tasks. Cognitive Science 1994; 18 (01) 87-122.
• 63 Patel VL, Kushniruk AW, Yang S, Yale JF. Impact of a computer-based patient record system on data collection, knowledge organization, and reasoning. J Am Med Inform Asso. 2000; NovDec 7 (06) 569-85.
• 64 Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc 2004; Mar-Apr 11 (02) 104-12. .
• 65 Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc 2006; Sep-Oct 13 (05) 547-56.
• 66 Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care--an interactive sociotechnical analysis. J Am Med Inform Assoc 2007; SepOct 14 (05) 542-9. .
• 67 Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc 2008; Jul-Aug 15 (04) 408-23.
• 68 Patterson ES, Rogers ML, Chapman RJ, Render ML. Compliance with intended use of Bar Code Medication Administration in acute and long-term care: an observational study. Hum Factors 2006; Spring 48 (01) 15-22.
• 69 Vogelsmeier AA, Halbesleben JR, Scott-Cawiezell JR. Technology implementation and workarounds in the nursing home. J Am Med Inform Assoc 2008; Jan-Feb 15 (01) 114-9.
• 70 Kushniruk AW, Kaufman DR, Patel VL, Levesque Y, Lottin P. Assessment of a computerized patient record system: a cognitive approach to evaluating medical technology. MD Comput 1996; Sep-Oct 13 (05) 406-15. .
• 71 Strauss AL, Fagerhaugh S, Suczek B, Wiener C. Social organization of medical work. Chicago, IL: University of Chicago Press; 1985
• 72 Overhage JM, Perkins S, Tierney WM, McDonald CJ. Controlled trial of direct physician order entry: effects on physicians’ time utilization in ambulatory primary care internal medicine practices. J Am Med Inform Assoc 2001; Jul-Aug 8 (04) 361-71.
• 73 Bates DW, Boyle DL, Teich JM. Impact of computerized physician order entry on physician time. Proc Annu Symp Comput Appl Med Care. 1994: 996
• 74 Han YY, Carcillo JA, Venkataraman ST, Clark RS, Watson RS, Nguyen TC. et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 2005; Dec 116 (06) 1506-12.
• 75 Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma’Luf N. et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999; JulAug 6 (04) 313-21.
• 76 King WJ, Paice N, Rangrej J, Forestell GJ, Swartz R. The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients. Pediatrics 2003; Sep 112 3 Pt 1 506-9.
• 77 Potts AL, Barr FE, Gregory DF, Wright L, Patel NR. Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics 2004; Jan 113 1 Pt 1 59-63.
• 78 Cordero L, Kuehn L, Kumar RR, Mekhjian HS. Impact of computerized physician order entry on clinical practice in a newborn intensive care unit. J Perinatol 2004; Feb 24 (02) 88-93.
• 79 Lehman ML, Brill JH, Skarulis PC, Keller D, Lee C. Physician Order Entry impact on drug turnaround times. Proc AMIA Symp 2001; 359-63.
• 80 Kuperman GJ, Gibson RF. Computer physician order entry: benefits, costs, and issues. Ann Intern Med 2003; Jul 1 139 (01) 31-9.
• 81 Horsky J, Kuperman GJ, Patel VL. Comprehensive analysis of a medication dosing error related to CPOE. J Am Med Inform Assoc 2005; JulAug 12 (04) 377-82.
• 82 Chan AJ, Islam MK, Rosewall T, Jaffray DA, Easty AC, Cafazzo JA. The use of human factors methods to identify and mitigate safety issues in radiation therapy. Radiother Oncol 2010; Dec 97 (03) 596-600.
• 83 Chan AJ, Islam MK, Rosewall T, Jaffray DA, Easty AC, Cafazzo JA. Applying usability heuristics to radiotherapy systems. Radiother Oncol 2012; Jan 102 (01) 142-7.
• 84 Kobayashi L, Parchuri R, Gardiner FG, Paolucci GA, Tomaselli NM, Al-Rasheed RS. et al. Use of in situ simulation and human factors engineering to assess and improve emergency department clinical systems for timely telemetry-based detection of life-threatening arrhythmias. BMJ Qual Saf 2013; Jan 22 (01) 72-83.
• 85 Kannampallil TG, Schauer GF, Cohen T, Patel VL. Considering complexity in healthcare systems. J Biomed Inform 2011; 44 (06) 943-7. .
• 86 Plsek PE, Greenhalgh T. Complexity science: The challenge of complexity in health care.. Bmj 2001; Sep 15 323 7313 625-8.
• 87 Weiss CH, Amaral LAN. Moving the science of quality improvement in critical care medicine forward. Am J Respir Crit Care Med 2010; 182 (12) 1461-2.
• 88 Wilson T, Holt T, Greenhalgh T. Complexity science: complexity and clinical care. BMJ 2001; Sep 22 323 7314 685-8.
• 89 Kannampallil TG, Cohen T, Kaufman D, Patel VL. Re-thinking Complexity in the Critical Care Environment. In: Patel VL, Kaufman D, Cohen T. editors. Cognitive Informatics in Health and Biomedicine: Case Studies on Critical Care, Complexity and Errors. London: Springer; 2014
• 90 Simon HA. The Sciences of the Artificial. Cambridge, MA: MIT Press; 1996
• 91 Berg M. Accumulating and Coordinating: Occasions for Information Technologies in Medical Work. Computer Supported Cooperative Work (CSCW) 1999; 8 (04) 373-401.
• 92 Patel VL, Cohen T. New perspectives on error in critical care. Curr Opin Crit Care 2008; 14 (04) 456-9.
• 93 Hollan J, Hutchins E, Kirsh D. Distributed cognition: toward a new foundation for human-computer interaction. ACM Transactions on Computer-Human Interaction 2000; 7 (02) 174-96.
• 94 Hutchins E. Cognition in the Wild. Cambridge, MA: MIT Press; 1995
• 95 Kirsh D. The intelligent use of space. Artif Intell 1995; 73 (01) 31-68.
• 96 Hazlehurst B, Gorman PN, McMullen CK. Distributed Cognition: An alternative model of cognition for medical informatics. Int J Med Inform 2008; 77: 226-34.
• 97 Patel VL, Kaufman DR, Arocha JF. Emerging Paradigms of Cognition in Medical Decision Making. J Biomed Inform 2002; 35: 52-75.
• 98 Xiao Y, Schenkel S, Faraj S. al. e. What white-boards in a trauma center operating suite can teach us about emergency department communication. Ann Emerg Med 2007; 50: 387-95.
• 99 Cohen T, Blatter B, Almeida C, Shortliffe E, Patel V. A cognitive blueprint of collaboration in context: distributed cognition in the psychiatric emergency department. Artif Intell Med 2006; Jun 37 (02) 73-83.
• 100 Patel VL, Zhang J, Yoskowitz NA, Green RA, Sayan OR. Translational Cognition for Decision Support in Critical Care Environments: A Review. J Biomed Inform 2008; 41 (03) 413-31.
• 101 Kannampallil TG, Li Z, Zhang M, Cohen T, Robinson D, Franklin A. et al. Making Sense: Sensor-based Investigation of Clinician Activities in Complex Critical Care Environments. J Biomed Inform 2011; 44 (03) 441-54.
• 102 Parlak S, Sarcevic A, Marsic I, Burd RS. Introducing RFID technology in dynamic and time-critical medical settings: Requirements and challenges. J Biomed Inform 2012; 45 (05) 958-74.
• 103 Vankipuram M, Kahol K, Cohen T, Patel VL. Toward automated workflow analysis and visualization in clinical environments. J Biomed Inform 2011; 44 (03) 432-40.
• 104 Lin L, Vincente KJ, Doyle JD. Patient safety, potential adverse drug events, and medical device design: a human factors engineering approach. J Biomed Inform 2001; 34: 274-84.
• 105 Karsh BT, Alper SJ. Work system analysis: the key to understanding health care systems. Advances in patient safety: from research to implementation. Rockville, MD: Agency for Healthcare Research and Quality; 2005. p. 337-48.
• 106 Roth EM. Uncovering the requirements of cognitive work. Hum Factors 2008; 50: 475-80.
• 107 Saleem JJ, Russ AL, Sanderson P, Johnson TR, Zhang J, Sittig DF. Current challenges and opportunities for better integration of human factors research with development of clinical information systems. Yearb Med Inform. 2009; 48-58.
• 108 Reddy M, Dourish P. A finger on the pulse: temporal rhythms and information seeking in medical work. Proceedings of the 2002 ACM Conference on Computer Supported Cooperative Work ACM Press; 2002. p. 344-53.
• 109 Abraham J, Kannampallil T, Almoosa K, Patel B, Patel VL. Comparative Evaluation of the Content and Structure of Communication using Two Handoff Tools: Implications for Patient Safety. J Crit Care In Press; 2014
• 110 Abraham J, Kannampallil TG, Patel VL. Analysis of Handoff Communication in Critical Care. J Biomed Inform 2012; 45 (02) 240-54.
• 111 Mamykina L, Hum S, Kaufman DR. Investigating Shared Mental Models in Critical Care. In: Patel V.L, Kaufman DR, & Cohen T. editor. Cognitive Informatics in Health and Biomedicine: Case Studies on Critical Care, Complexity and Errors. London: Springer; 2014
• 112 Kannampallil TG, Franklin A, Mishra R, Cohen T, Almoosa KF, Patel VL. Understanding the Nature of Information Seeking Behavior in Critical Care: Implications for the Design of Health Information Technology. Artif Intell Med 2013; 57 (01) 21-9.
• 113 Kannampallil TG, Jones LK, Patel VL, Buchman TG, Franklin A. Comparing the Information Seeking Strategies of Residents, Nurse Practitioners, and Physician Assistants in Critical Care Settings. J Am Med Inform Assoc. In Press 2014
• 114 Vankipuram M, Ghaemmaghami V, Patel VL. Adaptive behaviors of experts in following standard protocol in trauma management: implications for developing flexible guidelines. AMIA Annu Symp Proc 2012; 1412-21.
• 115 Patel VL, Kaufman DR, Cohen T. Cognitive Informatics in Health and Biomedicine: Case Studies on Critical Care, Complexity and Errors. London, UK: Springer; 2014
• 116 Womack JP, Jones DT. Lean Thinking. New York, NY: Free Press; 1996
• 117 Moody L. Human Factors and Lean in the ER: A Review of the Literature. Symposium on Human Factors in Healthcare 2012