Characterizing and Visualizing Display and Task Fragmentation in the Electronic Health Record: Mixed Methods Design

Abstract

Background The complexity of health care data and workflow presents challenges to the study of usability in electronic health records (EHRs). Display fragmentation refers to the distribution of relevant data across different screens or otherwise far apart, requiring complex navigation for the user’s workflow. Task and information fragmentation also contribute to cognitive burden. Objective This study aims to define and analyze some of the main sources of fragmentation in EHR user interfaces (UIs); discuss relevant theoretical, historical, and practical considerations; and use granular microanalytic methods and visualization techniques to help us understand the nature of fragmentation and opportunities for EHR optimization or redesign. Methods Sunburst visualizations capture the EHR navigation structure, showing levels and sublevels of the navigation tree, allowing calculation of a new measure, the Display Fragmentation Index. Time belt visualizations present the sequences of subtasks and allow calculation of proportion per instance, a measure that quantifies task fragmentation. These measures can be used separately or in conjunction to compare EHRs as well as tasks and subtasks in workflows and identify opportunities for reductions in steps and fragmentation. We present an example use of the methods for comparison of 2 different EHR interfaces (commercial and composable) in which subjects apprehend the same patient case. Results Screen transitions were substantially reduced for the composable interface (from 43 to 14), whereas clicks (including scrolling) remained similar. Conclusions These methods can aid in our understanding of UI needs under complex conditions and tasks to optimize EHR workflows and redesign.

Classification of Electronic Health Record–Related Patient Safety Incidents: Development and Validation Study

“…During this study, error types were adapted iteratively after several test rounds to develop a classification for reporting patient safety incidents in the clinical use of high-maturity EHRs. Some of the categories for error types have been identified in the scientific literature [13][14][15][16][17][18][19][20]; thus, their rationale exists. However, reliable classification work requires a solid knowledge of the features of an EHR system.…”

“…Owing to decreases in unplanned situations, we assumed that the hospital competence for EHR implementation has developed with experience from previous implementations. However, despite the new EHR system being a high-maturity EHR system, further efforts are recommended to improve its usability, make the medication section more user friendly, and devote more attention to the needs and perspectives related to clinical workflow in the development of EHR systems [12,13,[16][17][18]20,23,32]. In doing so, the EHR system provides even more benefits as a tool for clinicians to improve patient safety [22].…”

“…Data on error types specifically for high-maturity EHRs [10][11][12] remain scarce, and available studies have focused on EHRs from the earlier development stages; otherwise, the development stage is not described in detail [13]. Varied patient safety issues related to EHRs and documented in research include poor usability, inadequate communication of laboratory test results, EHR downtime, system-to-system interface incompatibilities, drug overdoses, inaccurate patient identification, care-related timing errors, and incorrect graphical display of test results [14][15][16][17][18][19][20].…”

Participatory Design of an Electronic Medical Record for Paediatric Palliative Care: A Think-Aloud Study with Nurses and Physicians

“…However, if they are not well developed, poorly implemented EMRs can have several unintended consequences [21,22]: large and unstructured data sets create a high cognitive demand for users to locate, contextualize, and summarize information [23]. In addition, they may create unintended workflow disruptions, causing cognitive and physical burdens because of the management of such workflows [24,25]. The resulting dissatisfaction with EMR use impacts healthcare professionals such as nurses and physicians, potentially leading to burnout, fatigue or stress and time pressure [26][27][28].…”

Participatory Design of an Electronic Cross-Facility Health Record (ECHR) System for Pediatric Palliative Care: A Think-Aloud Study

“…A common problem in the development and introduction of digital documentation systems is that they do not adequately address user needs [17]. Additionally, they do not support clinical workflows [18] or are characterized by poor usability [19]. To minimize these difficulties and increase acceptance, approaches in which systems are developed in a participatory design (originally co-operative design) process with future users are suitable [20,21].…”