Keywords
Human factors engineering - usability - patient safety - health information technology
1 Introduction
In the healthcare and bio-medical domains, health professionals, health researchers,
and increasingly patients are interacting with ever-greater numbers of digital information
systems, applications and services. From artificial intelligence and robotics through
to the internet of things (IoT), smartphone apps, and wearable computing, massive
amounts of health related data and information are being collected, analysed, and
exchanged, with the aim of delivering benefits from enhanced information access, accuracy,
and usability [[1]].
For governments, the healthcare industry, health professionals, and patients, digitisation
presents many transformative opportunities but also poses risks. At the broadest level,
improving the implementation of data security protocols and data privacy standards
continues to be recognised as critical for ensuring the protection of individual rights
and the functioning of mission critical health systems as we move ever closer to personalised
medicine [[2]]. For health professionals working in complex socio-technical care environments,
ensuring the delivery of safe and high quality care remains paramount when the introduction
of health information systems continues to produce unintended consequences [[3]]. While for patients, differences in technical, textual, and health literacy highlight
the risks of accentuating pre-existing inequalities as digital behaviour change interventions
become more common [[4]].
These risks and challenges are not new. From the early days of the ‘computer age’,
alongside considerable techno-centric optimism, many researchers recognised that successful
technology adoption and use relied on a range of factors. These included understanding
human factors, the human-computer interface, the organisational contexts of use, and
the complexity of the tasks to be undertaken [[5], [6], [7]]. In healthcare, for more than two decades, we have been actively engaged in developing
and deploying methods to explore human factors (HF) and the usability and safety of
health information systems, applications, and services [[8], [9], [10]]. Across the design, implementation, and evaluation of these systems, we have long
understood that most challenges result from a failure to design for the complexity
of socio-technical systems in healthcare and/or a failure to understand and engage
end-users in technology adoption and use in context [[11], [12], [13]]. Grappling with the complexity of socio-technical systems is not an easy task.
But HF approaches have been enhanced by recognising that the level of healthcare complexity
can be understood as depending on the number and degree of interrelatedness amongst
healthcare system components [[14]]. Similarly, socio-technical approaches do promote a focus on the interactions and
emergent properties of social systems and technological artefacts in context as part
of much contemporary HF research [[15], [16]]. Indeed for nearly twenty years, socio-technical models and frameworks suitable
to enhance HF and usability research have been deployed in healthcare environments
[[17], [18]] with more recent approaches specifically adapted to enhance the understanding of
complex adaptive healthcare systems [[19]].
Unfortunately, despite this depth of HF knowledge and the wide range of methodological
tools and techniques available, research continues to highlight contemporary evidence
of poor design, poor usability, technology-induced errors, and unintended consequences
from health information systems, applications, and services. In a recent systematic
review of the types and causes of prescribing errors arising from the use of computerized
provider order entry (CPOE) systems, Brown et al. [[20]] identified eight themes related to these errors including: computer screen display;
drop-down menus and auto-population; wording; default settings; non-intuitive or inflexible
ordering; repeat prescriptions and automated processes; users’ work processes; and
clinical decision support systems. They also highlighted evidence showing that a lack
of CPOE system flexibility directly contributed to users developing error-prone workarounds,
e.g. inclusion of, sometimes, contradictory free-text commentaries. In another systematic
review, Gephart et al. [[21]] examined available evidence on nurses’ experiences with the unintended consequences
of using electronic health record (EHR) systems. The results highlighted the impact
of EHRs on changing workflows in ways that may threaten patient safety, cause difficulties
in accessing information necessary for patient care decisions, and sometimes impact
on the efficiency of work.
The frequency and the volume of contemporary reporting on usability problems remain
a cause for concern. As the diversity of HIT grows, the persistence of usability issues
has led to considerable discussion and debate. As Ratwani et al. [[22]] and McCray et al. [[23]] highlighted, there is a need for more effective translation of our knowledge into
practice and for finding ways to enhance our impact on the usability and safety of
HIT systems being implemented. These themes have continued to be a focus in relation
to ongoing problems with major EHR systems. As Koppel et al. [[24]] pointed out, there is a danger when vendors of large EHR systems continue to limit
access to the data they hold on the software glitches, errors, and usability problems
exhibited by their systems. This resonates with earlier calls by Sinsky et al. [[25]] for improved transparency on comparative user experience data and greater clarity
on how it should be structured and reported. Unfortunately, while EHR usability challenges
are widely reported in the press [[26], [27], [28]], the human factors knowledge available to mitigate these problems has yet to be
applied consistently. Aligned to this, as Shanafelt et al. [[29]] have recently reported, is another unintended consequence from continued poor EHR
usability - that of increasing levels of clinician “burn-out” [[29]].
Beyond EHRs, another area with numerous reported usability issues relates to the widespread
diffusion of patient-centred e-Health applications and services. Wildenbos et al.
[[30]] and Baysari et al. [[31]] have investigated the extent to which HF knowledge is contributing (or not) to ensuring safe and usable designs and/or reducing unintended consequences for
patients as users. Purkayastha et al. [[32]] advocated for finding new ways to tailor approaches in this rapidly expanding area,
and Sawesi et al. [[33]] provided a systematic review on the impact of technology on patient engagement
and health behaviour change. This review highlights the need for more research, as
patients are encouraged to adopt and use ever greater numbers of health-related digital
applications and services.
This paper reviews recent developments in human factors (HF) research on the challenges
of health information technology (HIT) implementation and impact given the continued
incidence of usability problems and unintended consequences from HIT development and
use. A search of PubMed/ Medline and Web of Science® identified HF research published
in 2015 and 2016. Electronic health records (EHRs) and patient-centred HIT emerged
as significant foci of recent HF research. Following review, the authors selected
prominent papers highlighting ongoing HF and usability challenges in these areas.
This selective rather than systematic review of recent HF research highlights these
key challenges and reflects on their implications for the future impact of HF research
on HIT. The research presented provides evidence of continued poor design, implementation,
and usability of HIT, as well as technology-induced errors and unintended consequences.
The paper promotes support for:(i) strengthening the scientific evidence base on the
benefits and impacts of HF approaches;(ii) improving knowledge translation and dissemination
on how to practically implement HF approaches during design, implementation, and evaluation
of HIT; and (iii) increasing transparency, governance, and enforcement of HF best
practices at all stages of the HIT system development life cycle.
2 Technology, Human Factors, and Complex HealthCare Environments
2 Technology, Human Factors, and Complex HealthCare Environments
Understanding interactions within socio-technical systems and applying theory and
methods to these systems to optimise their design and usability remain at the heart
of HF research. To do this requires consideration of the organisational, physical,
and cognitive aspects of these systems, as well as the tools and techniques that ensure
they are developed to be ‘compatible with the needs, abilities, and limitations of
people’ [[34]].
In healthcare environments, the increased use of HF approaches has grown in response
to evidence of usability problems, technology-induced errors, negative outcomes in
terms of patient care and safety, and other unintended consequences from HIT [[35]]. Unsurprisingly, as HIT has become more pervasive and complex, there has been a
growing awareness of the need to evolve the approaches, tools, and techniques deployed
by HF researchers [[11], [13]]. As Patel et al. [[36]] have noted, numerous HF models have been developed to aid the understanding and
analysis of healthcare settings including: aviation-based models; macro-ergonomic
models for improving patient safety and quality; the systems engineering initiative
for patient safety (SEIPS); health professional performance models; and four stage
HF work system optimization model. However, in increasingly complex environments with
multiple interactions amongst people, technology artefacts, and contexts of use, the
relevance of socio-technical approaches for integrating and framing the use of different
models, tools, and techniques has been recognised. The socio-technical approach also
supports the incorporation of new tools and techniques that may better aid the implementation
of HF knowledge practice, e.g. clinical simulations, temporal methods for analysis,
and integration with quality improvement (QI) ‘lean’ methods [[36]].
As Kushniruk et al. [[37]] have recently discussed, a reflection on the evolution of HF and usability engineering
approaches to HIT is useful for stimulating thinking about how far we have come and
where the key future challenges lie. This is especially the case if we are to be able
to assess the success of our approaches in the design, implementation, and evaluation
of HIT for delivering improved patient care and system safety. Kushniruk et al. argued
that there is an increasing need to apply HF approaches earlier in the HIT system
development life cycle to reduce the incidence of technology-induced errors and optimise
system safety. Usability problems contributing to these errors are well known and
include screen navigation issues, inconsistent user interfaces, limited end-user feedback,
and poor system integration into the clinical workflow. Kushniruk et al. went on to
advocate for a ‘layered safety net approach to ensuring usability and safety'. This
approach employs a phased sequence of tests and mixed HF methods (e.g. cognitive walkthroughs,
heuristic evaluations, video-observations, clinical simulations) prior to HIT deployment. The aim is to increase the probability of identifying and rectifying
negative unintended consequences before HIT systems are released into healthcare environments
[[37]].
In the last twenty years, most HF approaches to HIT have been focused in three main
areas: (i) the analysis of healthcare work situations involving HIT; (ii) usability
studies of HIT; (iii) studies providing evidence or evaluation of the results of using
HF approaches on HIT. Combining these studies confirmed that much HIT had poor usability,
contributed to technology-induced errors and/or had unintended consequences in healthcare
environments. These studies also provided evidence that using HF approaches could
positively impact on adoption/use of HIT and may contribute to patient and system
safety [[38]]. However, it was readily acknowledged that there was a need to move rapidly towards
more standardisation of HF methods for analysing HIT and in reporting results; to
enhance translation/calibration of HF findings into tangible specifications for IT
designers; and to develop consistent methods for evaluating and validating the impact
of HF on HIT. Beyond this, it was also well-understood that the implementation of
most HIT was focused on configuring system features and functions to local circumstances
rather than on paying attention to usability or end-users contexts of use. Nearly
a decade on, it is perhaps sobering to reflect on how many of these issues continue
to resonate with contemporary HF concerns about HIT [[36], [37], [38], [39]].
As Beuscart-Zephir et al. [[39]] have discussed, governments and international bodies in a number of countries have
now introduced guidelines and regulations aimed at reducing medical errors, enhancing
the usability of HIT, and improving patient and system safety. However, despite these
developments, new research indicates that there remain a number of substantive, methodological,
and conceptual challenges inhibiting the widespread and systematic use of HF knowledge
in the design, implementation, and evaluation of HIT.
At the substantive level, the widespread adoption of EHR systems has stimulated a
large number of recent studies. Ratwani et al. [[22], [40], [41]] have raised serious concerns about continued poor usability in EHR design and implementation,
as well as limitations relating to the regulation around their certification; Babbott
et al. [[42]] have also reported negative impacts from poor EHR usability on increased clinician
stress extending to primary care [[42]]. Friedman et al. [[43]] have provided a useful typology of EHR workarounds in primary care [[43]]; and Graber et al. [[44]] have confirmed the continued occurrence of ‘adverse events associated with health
IT vulnerabilities causing extensive harm and mortality across the continuum of health
care settings’ [[44]]. At the same time, a systematic review by Ellesworth et al. [[45]] has questioned the quality of many published usability evaluations and identified
‘a paucity of quality published studies describing scientifically valid and reproducible
usability evaluations at various stages of EHR system development’. Ellesworth et
al. identified this lack of formal and standardized reporting of EHR usability evaluation
results as a major knowledge gap in the field. Similarly, in the rapidly emerging
area of patient-centred HIT, evidence on the use and impact of HF methods leaves many
questions unanswered especially in relation to ‘whether and to what extent’ these
methods mediate the safe use and positive impact of these technologies [[30], [31]]. As Yardley et al. [[46]] and Kayser et al. [[47]] also pointed out, the extent to which contemporary approaches are adequately engaging
patients and capturing their user needs in ways that meaningfully accommodate different
levels of technical, textual, and e-health literacy in technology design and implementation
remains unclear.
At the methodological level, recent research by Ammenwerth [[13]] has highlighted that with the increasing complexity of healthcare and HIT there
is a genuine need for more comprehensive evaluation studies and approaches to address
the challenges that pertain to ‘the quality of studies; publication bias; reporting
quality; availability of publications; systematic reviews and meta-analyses; training
of health IT evaluation experts; translation of evidence into health practice; and
post-market surveillance’. Following Ammenwerth et al. [[48]], it is also evident that alongside this need to enhance the evidence base, there
is a widespread awareness that much work is still to be done.
At the conceptual level, Kushniruk et al. [[37]] have also highlighted the gap that continues to exist between evidence, knowledge,
and insight within HF research. This gap inhibits the optimisation of usability and
safety of HIT and contributes to the ongoing prevalence of usability issues and problems.
Kushniruk et al. attributed part of this gap to a lack of appropriate knowledge translation
and limited dissemination and education of HF approaches within government, industry,
and society. Singh et al. [[49]] also acknowledged the gap but attributed it to the lack of a solid and convincing
conceptual foundation for use in practice. However, as Koppel [[50]] has argued, beyond these perspectives, most contemporary models of incident causation
at the interface between users and HIT are inadequate, overly static and potentially
hazardous if used as explanatory models. More fundamentally, as we move from studies
involving post-mortem descriptions of HF related problems with HIT to engage more
pro-actively in implementations of HIT and dynamic assessments of impact and outcomes,
there may be a need for reconfiguring our conceptualisation of the problems to be
addressed. As Coiera [[51]] has recently argued, maybe there is also a need for a ‘new informatics geography’
where we better understand and can quantify the value of information and the role
of HIT in realising that value per se.
Before discussing some of the more positive developments evident in recently published
HF research, it is useful to briefly review the recently published evidence of continued
poor design, implementation, and usability of HIT, as well as the reported evidence
of ongoing technology-induced errors and unintended consequences experienced by different
types of end users.
3 Technology, Human Factors and Usability: Old and New Problems
3 Technology, Human Factors and Usability: Old and New Problems
The diffusion and market dominance of a small number of very large vendors of complex
EHR systems has continued apace and now extends well-beyond North America. Solution
implementations of these large EHR systems tend to follow a familiar pattern regardless
of the individual product. A standard framework is modified and configured to achieve
local interoperability and terminological compliance. While vendors promote this approach
as being cost-competitive, it remains relatively unsuited to meaningfully tailoring
these systems to accommodate local user needs, user contexts, or workflow tasks.
In this context, it is perhaps unsurprising that, as these systems become more pervasive,
there has been an increase in reports of HF and usability problems with EHR systems
both in North America and internationally. Already by 2009, the US Healthcare Information
and Management Systems Society (HIMSS) EHR Usability Task Force [[52]] had identified, ‘usability as one of the main factors – possibly the most important
factor – hindering widespread adoption of EMRs’. More recently, as these EHRs have
become more ubiquitous, usability rather than low adoption has been identified as
an ongoing problem. Riskin et al. [[53]] have highlighted continuing issues including electronic records being difficult
to read and cumbersome to use with difficulties for users in being able to rapidly
identify essential information. They also identified how these usability problems
have been associated with new forms of technology-induced errors resulting from poor
information presentation and design and limited appropriate tailoring to end users,
their work tasks, or their contexts of use. Kellermann et al. [[54]] have raised the question as to what it will take to achieve ‘the as-yet-unfulfilled
promises of health information technology’. They argued that the disappointing performance
of HIT is primarily due to lack of ease of use, failure of healthcare providers and
institutions to re-engineer healthcare processes, and poor choice of systems in terms
of HF and interoperability. Perhaps one of the most problematic issues remains this
lack of user fit between systems procured by healthcare organizations on the basis
of organizational needs and actual user requirements and required usability in context
for clinical workflows on the ground.
Recognition of these problems has in recent years led to action by governments in
North-America and in Europe to require the use of validated HF and usability methods.
Although, as Beuscart et al. [[39]] have pointed out, many vendors and manufacturers continue to experience genuine
and practical difficulties in applying HF and usability methods beyond any mere reluctance
to respond to these new types of rules and regulations. Certainly these movements
towards regulation and certification of usability in HIT are to be welcomed and may
lead to positive improvements in the usability of systems, reduce technology-induced
errors, and mitigate unintended consequences. Vendors in both Europe and the USA are
already applying user-centred design techniques to comply with the European Medical
Device Directive [[55]] and USA certification requirements of the Office of the National Coordinator (ONC)
for HIT [[56]]. In the USA, ONC certification requirements involve vendors being required to provide
written statements on the development process they used, along with the results of
the usability tests conducted. However, Ratwani et al. [[22], [41]] have recently studied the current application of these certifications and found
they are generally weak with poor governance and oversight. One review conducted found
that 63% of the 41 vendors studied used only 15 study participants for usability testing,
and only 9% used at least 15 participants with any clinical background. These studies
highlight that HIT products can be certified for use with very limited and weak usability
analyses. This work shows that although it is a positive direction to include usability
certification, such certification must be conducted with much more rigor and in-depth.
These studies also echo the European experience with a clear need to systematically
improve knowledge of usability processes amongst HIT vendors given that many continue
to display misconceptions about user-centred design and usability processes [[22], [39], [40], [41]].
The American Medical Informatics Association (AMIA), the Agency for Healthcare Research
and Quality (AHRQ), and the National Institute of Standards and Technology (NIST)
have continued to explore ways to address these ongoing usability challenges. They
have also recently recognised that increased requirements for computer-based documentation
by health professionals to meet meaningful use requirements have contributed to further
human-computer interaction issues. This has led to reports of increased time and effort
expended by clinicians to document interactions with patients (i.e. increased number
of mouse clicks and steps needed to complete documentation of patient cases) [[56]]. In response, there have been numerous white papers workshops, webinars, and training
programs addressing the HF and usability challenges of EHRs. To specifically target
these issues, AMIA developed a task force that has generated 14 guiding principles
for improving usability in HIT. Following Middleton et al. [[57]], these principles include: consistency of design and standards, visibility of system
state, match between systems and world, minimalist design, minimization of memory
load, informatics feedback, flexible and customizable systems, useful error messages,
technology-induced error prevention, reversible actions, clear closure, user language
utilization, user control and appropriate help and documentation. Beyond these principles,
AMIA has also promoted a HF and usability research agenda to prioritize standardized
use cases for EHR functionalities, develop a set of measures for adverse events related
to health IT use, and research and promote best practices for safe implementation
of EHRs. AMIA have also identified the need for policy and regulatory changes and
made recommendations including: standardization and interoperability across EHR systems
should take into account usability concerns; establishment of an adverse events reporting
system for health IT and voluntary health IT event reporting; and the need for the
development and dissemination of an educational campaign targeting safe and effective
use of EHRs [[57]]. They also made recommendations focused on the health IT industry and clinicians.
For vendors, AMIA is promoting the development of a common user interface style guide
for selecting EHR functionalities and formal usability assessments on patient-safety
EHR functionalities, while for clinicians, there is encouragement for the adoption
of best practices during EHR system implementations, project management, and for the
reporting of IT-related adverse events.
Of course, the question of the impact of these and other types of initiatives on the
safety of HIT has also been an area of strong interest within recent HF research.
Magrabi et al. [[58], [59]] have used patient safety concepts to identify and classify the range and type of
unintended consequences arising from HIT. While Marcilly et al. [[60]] and Schiff et al. [[61]] have analysed and tabulated usability flaws and medication errors arising from
medication alerting systems and physician order entry systems respectively. Aligned
with these types of studies, Castro et al. [[62]] have recently identified 120 health IT-related sentinel events primarily associated
with the socio-technical dimensions of the human-computer interface, workflows, communications,
and clinical content.
Another area of HIT area that has been a recent focus for HF research relates to patients
as users of HIT. As was noted above, concerns about whether, and to what extent, HF
and usability research is contributing to ensuring safe and usable health technologies,
applications, and services require further analysis [[30], [31]]. But as Brenner et al. [[63]] noted in their systematic review exploring links between HIT and patient outcomes,
this is perhaps part of a broader problem as ‘many areas of health IT application
remain understudied and the majority of studies have non-significant or mixed findings’.
Similarly, Guise et al. [[64]] have identified patient safety risks associated with telecare and recommended greater
use of HF and usability approaches.
Interestingly, some attempts to resolve these issues in specific patient-centred HIT
interventions have recently been made. Matthew-Maich et al. [[65]] have produced a scoping review investigating mobile health technologies for managing
chronic conditions in older adults: they reported that most applications target specific
conditions, are designed primarily for use by patients and care providers, and that
evidence-based guidance on how to ensure acceptability and usability of mHealth innovations
continues to be limited. Zapata et al. [[66]] also explored mobile health technologies through a systematic review to investigate
usability evaluation processes. They highlighted the importance of usability for adoption
and use of mHealth by patients, many of them having limited experience and/or problems
using mobile applications. Based on their review, they recommended that usability
evaluation processes be enhanced by combining more than a single method when evaluating
mHealth. Queiros et al. [[67]] illustrated how rapidly HIT is developing in this area with a systematic review
of usability and accessibility in ambient assisted living (AAL) technologies. Their
review aims to understand how and to what extent user interaction occurs in AAL development
and evaluation processes. The results revealed a need to improve integration and interoperability
of existing technologies and to promote user-centred design and increased end-user
involvement to better address usability and accessibility issues.
This section has highlighted some of the recent HF research confirming evidence of
continued poor design, and implementation and usability issues with HIT. The recent
focus of HF research into EHRs and patient-centred HIT provides evidence of ongoing
technology-induced errors and unintended consequences experienced by a variety of
different end users including patients. Continuing challenges with EHRs include a
limited system ‘fit’ with users, contexts, and tasks that has contributed to negative
impacts on clinician workflow, clinician stress, and poor patient outcomes. For patient-centred
HIT, it is evident that there is still considerable work to do before we better understand
usability amongst different types of patients and the safety impacts and benefits
of rapidly emerging mobile and ambient technologies, applications, and services.
4 Discussion: Moving Forward
4 Discussion: Moving Forward
Despite the ongoing problems discussed above, this review has also identified a number
of positive developments and recommendations that make HF and usability research on
HIT progress Along with well-known HF successes in enhancing medication safety and
re-engineering discharge (RED), Kushniruk et al. [[37]] provided ample evidence that effective HF and usability methods, tools, and techniques
do exist. They also indicated that when these methods are applied correctly and early in the HIT system development life cycle, they can significantly improve usability,
reduce technology-induced errors, and mitigate unintended consequences. However, as
previously discussed in this paper, a major problem continues to be how to ensure
these approaches are actually embedded as integral components of all HIT development,
implementation, and impact assessment.
In the USA, Sheikh et al. [[68]] consider that some of the problems with HIT are the policy and regulatory settings
that support a fee-for-service paradigm that does not prioritise usability and interoperability.
To address these challenges, they have recommended ‘mandating vendors open-up their
application program interfaces (APIs)’. They also advocated ‘incentivising the development
of low-cost consumer informatics tools and improvements in the balance between data
privacy and reuse’. The National Patient Safety Foundation (NPSF) [[69]] and Zhang et al. [[70]] have also both made significant contributions to approaches that will practically
address many of the HF and usability issues with EHRs. For example, the NPSF has recommended:
greater transparency on health IT safety and best practices; identification and risk
mitigation related to adverse effects and unintended consequences of HIT; instantiation
of routine testing of system safety; and improved engagement of patients and their
families with HIT. Similarly, other national institutes including the NIST, AHRQ,
and ONC have made recommendations and guidelines to improve usability and safety of
EHRs [[71], [72], [73]]. The problem is not that we do not know what to do, but rather to make it happen!
Similarly in Europe efforts are underway to practically address the challenges of
usability with HIT. Kaipio et al. [[74]] have engaged in repeated national cross-sectional surveys with clinicians in Finland
to benchmark improvements over time with the usability of currently used EHR systems
in the period 2010–2014. While the results highlight continuing problems, this approach
appears to be one of the first national surveys of this type (i.e. focused on the
usability of EHRs). It also clearly provides information for healthcare providers,
decision makers, and politicians about the current state of EHR usability, differences
between vendor products, as well as options for improving EHR usability. Other practical
efforts to improve the implementation and impact of HIT through HF research have been
to use simulation to assess multi-functional systems in complex work situations as
conducted by Jensen et al. [[75]] in Denmark. There has also been the development of a knowledge base comprised of
evidence-based approaches to decrease technology-induced errors by Marcilly et al.
[[76]] in France. Lyon et al. [[77]] have developed the HIT academic and commercial evaluation (HIT-ACE) methodology
underpinned by user-centred design and implementation science approaches to aid stakeholder
decision-making related to HIT adoption and use. In Australia, the Commission for
Safety and Quality in HealthCare [[78]] has been active in developing practical resources to aid the safe implementation
and use of electronic medication management systems including guidelines with the
on-screen display of clinical and consumer medication information.
As highlighted by this brief selected review, steps are already underway within the
HF and usability research community to expand the impact of our research on the design,
implementation, and evaluation of HIT. It is clear that there is still much to do
and that moving forward will require action at multiple levels including: (i) strengthening
the scientific evidence base on the benefits and impacts of HF approaches; (ii) improving
knowledge translation and dissemination on how to practically implement HF approaches
during design, implementation, and evaluation of HIT; and (iii) increasing transparency,
governance, and enforcement of HF best practices at all stages of the HIT system development
life cycle.
5 Conclusion: It’s the Journey not the Destination that Matters
5 Conclusion: It’s the Journey not the Destination that Matters
This paper has reviewed recent significant developments in human factors (HF) research
relating to the ongoing challenges of implementation and impact of health information
technology (HIT) in the context of the continuing incidence of usability problems
and unintended consequences from its development and use. Based on the research reported
in this paper, there is a need for the discipline to continue to develop more calibrated
responses across the design, implementation, and evaluation of HIT to support moving
closer to embedding HF and usability knowledge into the development of a genuine safety
culture for HIT. Moving forward will involve HF researchers becoming more pro-actively
involved during HIT design and implementation, and in the dynamic assessment of our
impact on safer and more usable health technologies, applications, and services. In
addition, as a greater number of vendor-based systems (such as EHRs) are implemented,
the area of bringing usability engineering into their customization and deployment
also remains to be explored (and this may account to some extent for the continued
reports of usability problems). Recent evidence indicates that certification of product
development (i.e. certification of an EHR product development cycle) may not ensure
that it will be either usable or safe when the certified system is purchased by healthcare
organizations and deployed in a hospital setting that is likely to be far from the healthcare site(s) where it was developed. Indeed with the dominance
of a small number of large EHR vendors in North America and now internationally, the
evidence suggests that this is increasingly the case, with systems being deployed
in different healthcare systems, contexts, and countries from where these systems
were originally developed [[79]].
Beyond the increasing complexity of HIT, this paper has also highlighted the increasing
diversity of health technology, applications, and services. HF research must directly
grapple with the increasing diversity of HIT developed and deployed as part of healthcare
interventions, including those that engage patients and/or their family carers as
the primary users of these technologies, applications, and services. This suggests
that the practice of HF and usability research is not a destination per se, but rather
a journey. We must therefore explicitly recognise the dynamic and ever-changing relationships
that pertain in each socio-technical system involving technology, health professionals,
and patients. While this implies that we must be ready to tailor our approaches to
the circumstances and contexts we find in the field, we must also simultaneously find
meaningful ways to generate a stronger evidence base for our work.
As HIT becomes ever-more pervasive in healthcare including with patients as end-users,
there is also a need to expand our conceptualisation of the problems that are to be
addressed and the suite of tactics and strategies that we use across the design, implementation,
and evaluation of HIT. We must be willing to evolve and build partnerships with other
disciplinary colleagues, and we must also be careful not to over prioritise either
techno-centric or info-centric perspectives in our analyses. Following Martin et al.
[[80]], it is important that we reflect on what we are trying to achieve with HIT, as
they argue, for example, that medical records currently conceptualised as documentation
are ‘at risk of over-taking the delivery of care in terms of time, clinician focus,
and perceived importance’. They go on to argue that ‘complete and verbatim documented
accounts of any clinical encounter is not desirable and potentially harmful’ to the
aim of aiding cognition, communication, and care delivery that build relationships
and support decision-making – we must aspire to make sure HIT is not just usable and
safe but that it is of value to the primary goal of better care!
