Electronic Medical Record (EMR) systems are vital healthcare systems, ... or usage of EMR systems by physicians and hospitals. ... users as per requirements. In.
EMR Systems
Usability Issues with Electronic Medical Record Systems The technical revolution initiated by Information Technology (IT) and the Internet has had an impact on almost all domains including healthcare systems. The Electronic Medical Record (EMR) systems are vital healthcare systems, which are immensely contributing to today’s improved patient care. The rate at which EMR systems have been adopted in clinic and hospital settings is increasing day-by-day. There are several issues, which affect adoption, implementation or usage of EMR systems by physicians and hospitals. It can be observed that among these issues, usability issues are prominent. Many users are unable to utilize some major functions in EMR systems and get frustrated.
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Jan-Feb 2012 n Medical Equipment & Automation
EMR Systems
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he major usability issues with EMR systems are discussed in this article based on authors’ field studies and experiences with EMR systems.
Electronic Medical Record (EMR) and EMR Systems
fractures. An EMR system may be a part of a local stand-alone hospital Information System (hIS) or online healthcare system / website that allows creation, retrieval, updation, storage, deletion and administration of patient records. An EMR can be continuously updated and communicated with
Primary Users They include physicians, nurses, receptionists and/ or patients. These users have an authority to update EMR of a relevant patient partially or entirely. Secondary Users They include patient’s family, hospital administrators, IT infrastructure managers/ professionals, healthcare academicians, insurers, government officers, police or social workers. These users may refer to EMR of a relevant patient.
Usability Issues with EMR Systems Major usability issues observed with EMR systems are discussed in this section. Table 1 provides a comprehensive list of such usability issues:
Lack of Appropriate IT Infrastructure
Fig. 1: Sample EMR
An Electronic Medical Record (EMR) is a computerized medical record of a patient created in healthcare organization such as a hospital or dispensary that provides patient care. It is a record in digital format that is shared across different health care organizations. It may include a range of details including demographics, medical history, vital signs, allergies, immunization status, medication, laboratory test results, radiology images and billing information. Fig. 1 shows details in EMR such as admitted patient list as well as laboratory reports - x-ray and CT scan for a head injury patient with multiple Medical Equipment & Automation n Jan-Feb 2012
different healthcare systems or users as per requirements. In addition, data from EMR systems
An EMR system requires support of suitable IT infrastructure for its effective operation. IT-infrastructure is a distributed technical framework, which encompasses applications (e.g. Enterprise Resource Planning (ERP) systems, healthcare Information Systems (hIS)
Lack of Appropriate IT Infrastructure
Insufficient Integration in Electronic Form
User Training
Privacy and Confidentiality
Data Entry
Data Readability
Long-Term Preservation and Storage
Password Fatigue
Table 1: List of Usability Issues with EMRs
can be used anonymously for statistical reporting in matters such as quality improvement, resource management and public health surveillance.
Users of EMR Various users of EMR are classified as under:
or web applications), software (operating systems, security tools or middle-ware), data (e. g. EMRs or health-care policy documents), hardware (e.g. servers, printers or Uninterrupted Power Supply (UPS)) and network hardware (routers, gateways or switches). An inadequate IT infrastructure 31
EMR Systems may create a barrier for EMR usage keeping away some users including physicians working with a particular laboratory, room or department. Such a situation leads to the existence of parallel paperbased and EMR systems, which forces the related physicians and other users to switch between the systems, thereby slowing down workflow, requiring more time to manually enter data from external systems and increasing physicians’ resistance to EMR usage.
Insufficient Integration in Electronic Form EMR systems in many hospitals have not yet realized their full potential due to, in part, a lack of integration with associated physician offices. Many smaller physician practices generally have been less willing to implement EMR systems or they are not allowed to integrate electronically with EMR systems of bigger hospitals. So, many physician offices still continue to generate and use paper records with physical storage mechanism. Such fragmentation in patient records can lead to errors, duplications, and other costs associated with uncoordinated care. Expanding data access to external users such as remote clinics, referring physicians and specialists may be an important policy decision. It can lead to efficient patient care while raising many issues about information security, responsibility of decision-making and medicolegal aspects.
User Training EMR systems provide several functionalities with higher level 32
of complexity. It may take time for naive users to understand what can be done and how to do it. This is a major issue with the navigational structure of EMR systems, which contain hundreds of screens that need to be accessed using tabs, buttons, and hyperlinks. The time to set up and learn to use such a system is often a challenge. Physicians are introduced to EMR systems and later receive 1-2 hour training sessions at times and locations convenient for them. Nurses and other users may receive 4-8 hour classroom training. Refresher training is given as needed through workshops, classroom discussions and individual training.
Privacy and Confidentiality The relationship among healthcare providers and patients is based on intimacy and trust. Privacy and confidentiality are embedded implicitly in such relationships and interactions. With the advent of computers, networking and Internet, patient’s privacy and confidentiality are at stake. Many activities associated with EMR systems such as electronic charting and prescription distribution have resulted in breaches of patient confidentiality in ways that would have been unthinkable earlier. The sale of data from such sources to insurers, private companies, government agencies and financial institutions has become widespread. The primary threats to the confidentiality of patient information originate from the lack of controls over the legitimate demands for data made by other entities such as healthcare
researchers, insurers and public health agencies.
Data Entry A data entry for EMR systems may be performed by physicians, nurses, receptionists or even operators. Many of younger physicians tend to be touch typists, while older physicians tend to prefer dictations to assisting nurses. The timing of data entry can be highly variable. Some physicians enter the data in the patient’s presence, while others wait until the patient has left the examination room. Waiting until the end of the day to enter the data is potentially risky as it relies on faulty human memory to reconstruct what occurred hours earlier. The process for data entry lacks standardization. For example, there are more than 20 ways of just writing patient names in hospitals. There may not be a uniform policy about responsibility of data entry at various stages of patient care. Some busy users may complain about increased workload due to data entry and its subsequent ill-effects on patient care. Many users have reported having accidently entered wrong orders for a patient or orders for a wrong patient.
Data Readability The readability of data in EMRs presented on device display is affected by various attributes such as simplicity, naturalness, data density, color, display technology and local language usage. A default font size preferred for important content should not be smaller than 12-point and never smaller than 9-point for any data. High contrast between text Jan-Feb 2012 n Medical Equipment & Automation
EMR Systems and background is also important; black on white is the most readable in healthcare environment. Also, users of EMR systems must be able to scan relevant information quickly with high resolution.
Long-Term Preservation and Storage An EMR may be required / referred throughout the lifetime of a patient. Therefore, long-term preservation and storage of EMRs is an important consideration in patient care. There is a lack of consensus on most of the related issues such as the duration to store EMRs, methods to ensure the future accessibility / compatibility of archived data with yet-to-be developed retrieval systems and how to ensure the physical and virtual security of the EMR archives. Many of these issues depend upon national/state regulations, supporting IT infrastructure and public awareness, which may change over a period of time.
Password Fatigue Every healthcare organization may have its own security policy requiring even more complex passwords with a combination of numbers and case-sensitive characters. Often, users of EMR systems are forced to change their passwords frequently, which may create relentless password fatigue leading to login error issues and making EMR access really difficult. Therefore, EMR users should be given necessary guidelines as well as freedom in password selection. Thus, the designers and users of EMR systems should consider all the above-mentioned usability issues in EMR system implementation and usage for Ì faster and efficient patient care.
Ganesh Bhutkar
Ganesh Bhutkar is Indian Academician and Usability Researcher. He is M.E. (Comp. Engg.) and MBA from University of Pune. He is currently pursuing PhD in Medical Usability at IDC, IIT Bombay. He is also Assistant Professor at Vishwakarma Institute of Technology, Pune and has about 16 years of academic experience and has published research papers in many relevant International Conferences and Journals.
Rahul Wankhede, Nidhin Thomas, Dheeraj Sheth and Siddhanth Shetty are currently pursuing their graduation (BTech) in Computer Engineering at Vishwakarma Institute of Technology, Pune, India.
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