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

Overview

Journal JMIR Hum Factors

Specialty Health Services

Date 2020 Oct 21

PMID 33084580

Citations 9

Authors

Yalini Senathirajah

David R Kaufman

Kenrick D Cato

Elizabeth M Borycki

Jaime Allen Fawcett

Andre W Kushniruk

Affiliations

Soon will be listed here.

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.

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References

Unertl K, Weinger M, Johnson K, Lorenzi N . Describing and modeling workflow and information flow in chronic disease care. J Am Med Inform Assoc. 2009; 16(6):826-36. PMC: 3002133. DOI: 10.1197/jamia.M3000. View

Zheng K, Haftel H, Hirschl R, OReilly M, Hanauer D . Quantifying the impact of health IT implementations on clinical workflow: a new methodological perspective. J Am Med Inform Assoc. 2010; 17(4):454-61. PMC: 2995654. DOI: 10.1136/jamia.2010.004440. View

Patel V, Kushniruk A, Yang S, Yale J . Impact of a computer-based patient record system on data collection, knowledge organization, and reasoning. J Am Med Inform Assoc. 2000; 7(6):569-85. PMC: 129666. DOI: 10.1136/jamia.2000.0070569. View

Kushniruk A, Borycki E, Kuwata S, Kannry J . Predicting changes in workflow resulting from healthcare information systems: ensuring the safety of healthcare. Healthc Q. 2006; 9 Spec No:114-8. DOI: 10.12927/hcq..18469. View

Borycki E, Lemieux-Charles L, Nagle L, Eysenbach G . Evaluating the impact of hybrid electronic-paper environments upon novice nurse information seeking. Methods Inf Med. 2009; 48(2):137-43. DOI: 10.3414/ME9222. View

Senathirajah Y, Kaufman D, Bakken S . Cognitive Analysis of a Highly Configurable Web 2.0 EHR Interface. AMIA Annu Symp Proc. 2011; 2010:732-6. PMC: 3041363. View

Gray W, Sims C, Fu W, Schoelles M . The soft constraints hypothesis: a rational analysis approach to resource allocation for interactive behavior. Psychol Rev. 2006; 113(3):461-82. DOI: 10.1037/0033-295X.113.3.461. View

GRAY W . Milliseconds matter: an introduction to microstrategies and to their use in describing and predicting interactive behavior. J Exp Psychol Appl. 2001; 6(4):322-35. DOI: 10.1037//1076-898x.6.4.322. View

Campbell E, Sittig D, Ash J, Guappone K, Dykstra R . Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006; 13(5):547-56. PMC: 1561794. DOI: 10.1197/jamia.M2042. View

10.

Calvitti A, Hochheiser H, Ashfaq S, Bell K, Chen Y, El Kareh R . Physician activity during outpatient visits and subjective workload. J Biomed Inform. 2017; 69:135-149. DOI: 10.1016/j.jbi.2017.03.011. View

11.

Kushniruk A, Kaufman D, Patel V, Levesque Y, Lottin P . Assessment of a computerized patient record system: a cognitive approach to evaluating medical technology. MD Comput. 1996; 13(5):406-15. View

12.

Duncan B, Kaufman D, Zheng L, Grando A, Furniss S, Poterack K . A micro-analytic approach to understanding electronic health record navigation paths. J Biomed Inform. 2020; 110:103566. DOI: 10.1016/j.jbi.2020.103566. View

13.

Zheng K, Padman R, Johnson M, Diamond H . An interface-driven analysis of user interactions with an electronic health records system. J Am Med Inform Assoc. 2008; 16(2):228-37. PMC: 2649313. DOI: 10.1197/jamia.M2852. View

14.

Unertl K, Novak L, Johnson K, Lorenzi N . Traversing the many paths of workflow research: developing a conceptual framework of workflow terminology through a systematic literature review. J Am Med Inform Assoc. 2010; 17(3):265-73. PMC: 2995718. DOI: 10.1136/jamia.2010.004333. View

15.

Helmers R, Doebbeling B, Kaufman D, Grando A, Poterack K, Furniss S . Mayo Clinic Registry of Operational Tasks (ROOT): A Paradigm Shift in Electronic Health Reco Implementation Evaluation. Mayo Clin Proc Innov Qual Outcomes. 2019; 3(3):319-326. PMC: 6713835. DOI: 10.1016/j.mayocpiqo.2019.06.004. View

16.

Zheng L, Kaufman D, Duncan B, Furniss S, Grando A, Poterack K . A Task-Analytic Framework Comparing Preoperative Electronic Health Record-Mediated Nursing Workflow in Different Settings. Comput Inform Nurs. 2020; 38(6):294-302. DOI: 10.1097/CIN.0000000000000588. View

17.

Roman L, Ancker J, Johnson S, Senathirajah Y . Navigation in the electronic health record: A review of the safety and usability literature. J Biomed Inform. 2017; 67:69-79. DOI: 10.1016/j.jbi.2017.01.005. View

18.

Kushniruk A, Senathirajah Y, Borycki E . Towards a Usability and Error "Safety Net": A Multi-Phased Multi-Method Approach to Ensuring System Usability and Safety. Stud Health Technol Inform. 2018; 245:763-767. View

19.

Ellsworth M, Dziadzko M, OHoro J, Farrell A, Zhang J, Herasevich V . An appraisal of published usability evaluations of electronic health records via systematic review. J Am Med Inform Assoc. 2016; 24(1):218-226. PMC: 7654077. DOI: 10.1093/jamia/ocw046. View

20.

Senathirajah Y, Borycki E, Kushniruk A, Cato K, Wang J . Use of Eye-Tracking in Studies of EHR Usability - The Current State: A Scoping Review. Stud Health Technol Inform. 2019; 264:1976-1977. DOI: 10.3233/SHTI190742. View