Mitigating Display Fragmentation in the Electronic Health Record with the MedWISER Composable Approach: A Mixed Methods Design (Preprint)
Authors: Senathirajah Yalini , Kaufman David R. , Cato Kenrick D. , Borycki Elizabeth M. , Fawcett Jaime Allen , Kushniruk Andre W 
Published: November 2020

BACKGROUND

Navigational complexity can present formidable challenges for electronic health record (EHR) users. The fragmented design of conventional EHRs can contribute to increased cognitive load for clinician users and poor fit-to-task. First, the ‘keyhole effect’ describes the phenomenon in which due to the large volume of information and limited screen size, users cannot see all information on the same screen (like only seeing part of a large room through a small keyhole). Needed information is spread across several screens, creating fragmented displays and information. This can increase cognitive load – or the use of limited working memory resources – as users must navigate to a screen, identify useful information, and then hold that information in working memory as they navigate to another screen. For clinicians navigating EHRs, this has consequences for patient care as cognitive resources (perception, attention, and memory) are known to be limited. As clinicians expend more cognitive resources navigating and processing information from an EHR, they have fewer cognitive resources for patient care tasks and diagnostic reasoning, leading to possible error. Additionally, two key contextual factors in healthcare settings need to be addressed by EHRs to enable better fit-to-task: (1) clinicians often communicate information via patient records, thus the EHR needs to facilitate that communication; and (2) physicians are prone to interruptions as part of their workflow, which can lead to errors or omissions in perceiving information. Reducing fragmentation in EHR design has the potential to reduce cognitive load and enhance fit-to-task for clinician users.

OBJECTIVE

Introduce a novel composable approach to EHR design implemented as MedWISER, a composable system where users can freely assemble needed information on the same screen, thus reducing fragmentation. This study protocol introduces methods by which to assess MedWISER’s potential to address the keyhole effect and poor fit-to-task problems by reducing cognitive load, enhancing communication, and mitigating the impact of workflow interruptions.

METHODS

This multi-study project will involve qualitative and quantitative methods to evaluate how conventional EHRs and the composable approach affect clinician performance. Methods include think-aloud protocols, task completion, simulation studies, screen capture and eye tracking, and interviews and surveys. Key measures include time to complete tasks, error detection/omission, completeness of information review, and gaze direction. Subjects will be clinicians from large university hospital settings.

RESULTS

This project is supported by the Agency for Healthcare Research and Quality. Data collection and analysis is anticipated to conclude in Spring 2021.

CONCLUSIONS

Together these studies allow investigators to successfully investigate a range of challenges and contexts associated with EHR design, cognitive load, safety, and fit-to-task and evaluate the usefulness of the composable EHR design in meeting them.

CLINICALTRIAL

The following is not a clinical trial.