How does poor EMR usability lead to medical errors? Raj Ratwani, PhD, director of the MedStar Health National Center for Human Factors in Healthcare, explains that it often has to do with the visual display of information.
“The basic usability concept is you want to only display information that is relevant to the user at that time. You want to display [information] in a way that is visually effective [so that] it guides the way [clinicians] think and reason with the information,” he says.
Ratwani shares one example from his research of what can happen when one does not adhere to this concept in the design or implementation of EMR programs. “A physician was asked to search and order Tylenol 500 mg. The clinician put in the word ‘Tylenol’ for a male patient under age 20,” he relates. “In this instance, the physician got 86 different results.”
The results included things like children’s Tylenol, infant’s Tylenol, Tylenol for women, and many other results that were completely irrelevant to the physician’s order, raising a significant usability problem.
“What happens from a safety perspective when you present a physician with 86 different options is you are increasing the likelihood that the physician is going to select the wrong medication and potentially select the wrong dose of the medication,” Ratwani says. “With Tylenol, that is a lower-risk medicine, so it may not be a grave concern, but certainly you could imagine several other types of medicines, such as opioids, where these really complex lists are very, very difficult for our physicians to maneuver.”
These types of circumstances introduce what Ratwani refers to as cognitive burden.
“It is too much information. If you think about how many times a physician has to search through all of the information [in an EMR], it becomes very problematic,” he says.
Another example of a usability concern relates to data entry. “The concept is that you want to make it very easy for physicians and other clinicians to enter information into the system,” Ratwani says. “It should be intuitive.”
However, Ratwani notes that he has seen examples in pediatric cases where the interfaces are confusing. The clinician entering information regarding a child’s weight may put the data in the wrong field or in the wrong units, substituting pounds for kilograms or vice versa. “The reason that is so important for children is because children’s medicines ... [use] weight-based dosing. That is actually critical to the effectiveness and safety of the medicines,” he explains.
Therefore, if an emergency physician enters a child’s weight incorrectly (perhaps the number entered is too high), then the dose of the medication may be stronger than what the patient can tolerate safely.
“It can lead to serious harm and even death ... this is another example of where the entry of the information is critical,” Ratwani says. “We are seeing serious usability challenges that could lead to harm.”