by adgrooms on June 14, 2019

The ability to retrieve patient information on a computer is an improvement over the paper filing system of years past. Some benefits have yet to be realized but among them are the potential to give patients greater access to their information, doctors greater visibility into patient history, and researchers a wider view to learn more about our health. But this transformation has brought unanticipated pitfalls.

When we talk about user experience (UX) in EHRs, often we talk about how it is hard to navigate. The screens are cluttered, and in general, it takes unnecessary time to accomplish straightforward, common tasks. The real danger is the effect of cognitive overload on the user that in turn produces mental fatigue. Are EHRs detrimental to decision making?

The human brain uses three types of memory:

  • Sensory memory, where incoming information is first received and filtered

  • Working Memory, where critical thinking and problem solving happen

  • Long Term memory, where information is categorized and stored

Physicians have to make many high-risk decisions every day, which requires a high level of thinking and understanding of complex problems. This is primarily done in working memory. However, working memory has limited capacity and different types of information use up working memory's capacity at different rates.

Cognitive load theory shows how different information uses the working memory. Intrinsic cognitive load is the complexity or weight of a task. These are the high stakes decisions that physicians make all day pertaining to patient care. Extraneous cognitive load is determined by the organization of a task or information. This is where poorly designed UX in an EHR can have a detrimental effect on the overall cognitive load. Overly cumbersome systems and processes leave less space for patient care decisions.

How do we improve the situation for physicians? We need to talk about what information is shown and how it is presented in the EHR system. Asking providers to adjust thinking to varied layouts between systems slows workflow and produces cognitive load. A standardized design will make EHR more familiar and consistent, and reduce mental burden.

Borrowing from aviation, EHR developers can design systems with fewer interruptions such as clicking to new windows to find information. The transition between windows causes "blink" attention diversion that can last up to 90 seconds. A well-designed tool will have all of a patient's relevant information available for the physician to view in one window.

One study found that enhanced decision-making support in EHR resulted in less cognitive load and better clinical performance. Enhanced decision-making means providing clear, simple decision pathways based on a standard procedure to information that is needed for a particular patient. It reduces the need for thinking inside the computer system so that the provider can focus on thinking about the patient.

The frustrating thing is that these are not new or unproven ideas. They are simple, well-known, well-tried usability techniques that urgently need to be applied to medical systems. We do not recommend this lightly. Applying a massive user-interface redesign is disruptive. It means yet another round of training and another round of adaptation. There is a high cost to change. The cost to remain the same is much much higher.