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In defense of necessary clicks: The science behind usability

If there’s one thing we know about EHRs, users hate clicks. And for good reason. Clicking and scrolling historically have represented extra time, effort and evidence of not understanding an efficient workflow. Click reduction is often cited as the best way to improve electronic health record (EHR) usability. Our gut instinct tells us that we should do everything we can to reduce clicks.

Yes, unnecessary steps are annoying and should be removed. But we have to be careful that we don’t actually increase cognitive load, hinder decision making and reduce overall efficiency and satisfaction in our zeal to reduce clicks and scrolling. There is a great deal of research available that should guide the design, implementation and customization of EHR interfaces.

In the evidence-based practice of medicine, scientific evidence should also guide Health IT usability decisions. Some of these known facts that come from a solid foundation of research results include:

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.

Data vs. Instinct – Which will win out in usability decisions?

The industry recognizes we need to improve EHR usability. Decisions about design and usability should not be based on instincts or “gut feel.” Designers should follow specific guidelines that they all too often ignore in favor of other considerations. For example, using brand colors for text and background on a web page might fit visual branding standards, but it could create a readability issue if the colors don’t have a good contrast ratio.

There are three main things we should do as an industry that will help advance usability:

1) Believe the science. We rely on scientific evidence to guide clinical decisions, we should adhere to the same standards for usability. Rely on data to understand the tradeoffs with every decision. For example, we can get more information on a screen to remove clicks and scrolling, but reducing the font size to do it will make reading slower, more difficult, and more error-prone.

2) Participate with and hold vendors accountable. EHR vendors need honest, consistent input. Work with them and point out trouble spots. Let them know when readability is compromised. Point out unnecessary clicks, but recognize that a narrow focus on clicks can mean exchanging one source of pain with another that could be worse for safety and satisfaction.

3) Be open minded. Some new interactions may not feel right or familiar at first, but if it’s based on good data it will help improve efficiency, effectiveness and satisfaction. When they’re based on research and best practices for user-centered design, you will likely find that they improve your overall experience with related tasks.

By embracing these principles, we can steer usability away from “gut feel” and make data-driven, evidence-based design decisions.

Editor’s Note: For more examples and references, Allscripts clients can access Ross Teague’s “Science of Usability” presentation on ClientConnect. Two additional useful references include Universal Principles of Design by William Lidwell, Kritina Holden, and Jill Butler; and Universal Methods of Design by Bella Martin and Bruce Hannington.

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