Clinicians can no longer adapt to increased cognitive burdens from electronic health record (EHR) and health information technology (IT) systems. The industry has reached a saturation point and must do more to improve provider wellness. Here are four ways we can start:
1. Acknowledge how health IT impacts provider wellness.
“Provider wellness” and “clinician well-being” are terms that describe the state of how physicians and other healthcare professionals are feeling, professionally and personally, because of their day-to-day experience delivering care. The concepts relate to industry-wide attempts to improve clinician satisfaction and thus the patient experience and their safety.
Recent studies highlight many causes of provider burnout and the impact it can have on patients and clinicians alike1, 2, 3. The demands of an increasingly complex healthcare environment and elevated requirements related to health IT use are affecting them every day.
The human part of any system is extremely adaptable. Humans can adapt to less-than-optimal conditions and continue to achieve task success (e.g., documenting a patient note in the EHR or seeing a certain number of patients in a day).
2. Understand the costs of clinicians adapting to less-than-ideal health IT.
What is often not acknowledged is that this adaptation comes at a cost, and these costs are frequently not visible until they reach a breaking point. Safety and decision making suffer, as well as the emotional and physical well-being of the users.
An example of this natural adaptation can be seen in the response to information overload. When humans are barraged with too much data, they adapt by leveraging cognitive shortcuts, such as outcome bias, next-in-line effect and authority bias. These responses help us make decisions and continue to move forward on a short-term basis, but they can also lead to bad decisions, missed important information, and errors4.
Frequently, technology users who feel physical and cognitive burdens are not aware of the cause and cannot accurately describe the reason for their frustration. For example, many clinicians ask for new features, more data displayed or reduced clicks, because it’s how they communicate their need for something to change. But when we provide those additional features, most of the time it does not result in a happier, less burdened user.
This is because users evaluate a product for what it enables them to accomplish in a given set of circumstances5. They may require features to accomplish tasks, but the effort to improve our technology (even if well-designed from a feature perspective) must be done within the context of the broader goals/jobs/activities the user is trying to accomplish or it only adds to their burden.
3. Follow principles from the science of usability.
At the most basic level, scientific evidence should guide Health IT usability decisions. We must keep these principles in mind:
Processing fluency – When users encounter cognitive hurdles caused by poor EHR design, they are more likely to judge the task as more difficult and task performance suffers. So it is important to remove anything that interrupts processing fluency. For example, the date format “10/5/16” requires the user to translate the number 10 into October, whereas “Oct. 5, 2016” is faster for the user to process, and is more globally understandable. Removing these processing interruptions will increase overall satisfaction and performance.
Readability – The more “readable” text is, the better your comprehension rates will be. Studies have shown that sentence length, contrast, font size and color all play a role in how easily a reader will be able to understand information. Follow best practices, and the user is less likely to experience eye strain, miss important information or waste valuable time.
Fear of emptiness – Also known as Horror Vaccui, is the idea that people have a natural urge to fill blank spaces. Ironically, the more we fill blank spaces with objects or information, the perceived value decreases.
Cognitive tax – When two or more perceptual or cognitive processes are in conflict, it requires additional processing to resolve the conflict, and the additional time and effort have a negative impact on performance. Decision-making research shows us that not only can more information be more cognitively taxing, but it can also lead to suboptimal decisions.
Too often we ignore this knowledge, albeit with the best of intentions. We hope that adding a requested feature or removing a frustrating extra click by shrinking the font or filling the screen with more data will not cause the dissatisfaction that we know, logically, will result. Well-intentioned or not, it still relies on the human adapting to the system.
4. Design with a focus on reducing the clinician’s cognitive load.
We must design with a greater focus around fundamental goals our users have for our technologies, paying special attention to where we are leveraging human adaptability (intentionally or not). At Allscripts, we conducted research across our client base to learn more about where our clients are focused, looking past their initial usability complaints and suggestions to instead understand their root goals in using health IT.
We learned that most of their mental effort, time and clicks are geared toward three categories of activity:
1. Orientation to a patient’s history, current medications/problems and plan,
2. Effective listening to a patient while they document and
3. Identification of the most clinically-relevant information buried in volumes of data.
We now know that if we can adjust our products to free our clients to process and act on what is most important, it will reduce the cognitive load and significantly improve their experience.
The issue of provider wellness in today’s environment is a significant one. Regulations are adjusting to try to address clinician burden. That effort is a good first step because undoubtedly burdensome regulations play a factor in this conversation. However, if we are going to successfully shift our delivery system to one that is value-driven (and thus data intensive), technologists must have an even stronger focus on addressing clinician burden.
The days of relying on clinicians to adapt to an increasingly complex healthcare system to deliver safe, high quality care – without experiencing a degree of burnout – have come and gone. We must all take a hard look at where we can do better.
1 https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/ahrq-works/impact-burnout.pdf
2 http://www.annfammed.org/content/15/5/419.full
3 http://www.healthcareitnews.com/news/big-wave-artificial-intelligence-and-machine-learning-coming-healthcare-university-hospitals
4 https://betterhumans.coach.me/cognitive-bias-cheat-sheet-55a472476b18
5 https://hbr.org/2016/09/know-your-customers-jobs-to-be-done