a Department of Internal Medicine, University Hospital Basel, Switzerland; b Department of Informatics, University Hospital Basel, Switzerland
Little is known about the key demands of clinicians in regard to hospital information systems (HISs). We therefore aimed to describe important characteristics of a user-friendly HIS from a clinician’s perspective.
In November 2015, we consecutively emailed two anonymised web-based surveys to all clinicians working at the Department of Internal Medicine of the University Hospital Basel. The surveys did not focus on a specific HIS. The first survey asked for the single most important characteristic of a userfriendly HIS and the second survey requested respondents to further subcategorise these characteristics.
The response rates for the first and second survey were 48.2% (40/83 clinicians) and 39.8% (33/83), respectively. In the first survey, the most frequently mentioned characteristics of user-friendly HISs were “rapid retrieval of relevant clinical data” in 47.5% (19/40), an “easy-to-use interface” in 15.0% (6/40) and a “simple visual design” in 15.0% (6/40). In the second survey, clinicians divided the main characteristic “rapid retrieval of relevant clinical data” into the following subcategories: a “simple software architecture” in 97.0% (32/33), the “availability of strong search tools” in 93.9% (31/33), the “presence of only few interface layers” in 72.7% (24/33), an “automatic alerting system” in 63.6% (21/33) and an “overview of important clinical data in one window” in 54.5% (18/33).
In conclusion, the clinicians’ top priority in regard to HISs was the ability to quickly find relevant patient information. Developers of HISs should particularly focus on creating intuitive interfaces with powerful search engines and clear visualisation of clinical data.
Key words: architecture; clinical data; electronic medical record; evaluation; hospital information system; user interface; satisfaction; software; survey; usability
As clinicians spend a substantial amount of working time handling electronic clinical data, hospital information systems (HISs) should be user-centred to optimally support patient care and workflow [1, 2]. However, little is known about the key demands of clinicians in regard to HISs.
The evaluation of HISs is of great importance as implementation of an HIS can increase the rate of medical errors [3–10] and as software interfaces should specifically meet the end-users’ needs (i.e., usability)  to improve productivity, enhance user well-being, avoid stress, increase accessibility and reduce risk of harm [12, 13]. Usability has been defined in an International Organization for Standardization (ISO) standard as “the extent to which a system can be used by specific users to achieve specified goals with effectiveness, efficiency and satisfaction in a specific context of use” [12, 13]. Others proposed a more specific usability definition of an HIS, which is based on three dimensions: (i) “compatibility between HIS and clinicians’ task”; (ii) “HIS support for information exchange, communication and collaboration in clinical work”; and (iii) “interoperability and reliability” .
There are several psychological methods to evaluate usability when developing software systems, such as the heuristic evaluation, the cognitive walkthrough and the think aloud methods . In addition, there are a number of validated questionnaires that measure endusers’ perception of usability of software systems (e.g., System Usability Scale [SUS], Questionnaire for User Interface Satisfaction [QUIS], Health-IT Usability Evaluation Scale [Health-ITUES]) [16, 17]. Studies have used these instruments to evaluate the usability of specific HISs and clinical decision support systems [15, 16, 18–20]. But despite the fact that most software developers pay attention to the usability of HISs , clinicians have common needs, which most HISs have not yet fully met .
In the process of improving our HIS we aimed to describe important characteristics of user-friendly HIS from a clinician’s perspective.
We performed a survey-based cross-sectional study by consecutively e-mailing two anonymised web-based surveys to all clinicians working at the Department of Internal Medicine of the University Hospital Basel (USB) – a tertiary referral centre in Northwestern Switzerland with 712 beds, and treating around 34 000 hospitalised patients and about 180 000 outpatients per year. As part of an internal quality evaluation, clinicians had one week to respond to each of these surveys (for details see supplements). The first and second surveys were sent on the 5th and 23rd November 2015, respectively. Each survey took only one to two minutes per person to complete.
Clinicians at the USB work with two main HISs, ISMed© (Protect Data AG, Boswil, Switzerland) and Meona (Meona GmbH, Freiburg, Germany), including multiple subsystems for specific purposes (e.g., a pathology information system, picture archiving and a communication system). The surveys did not focus on a specific HIS. We created the survey questions and hierarchy based on the pooled written feed-back of clinicians at the Department of Internal Medicine concerning the usability of HISs in general to cover optimally their demands in daily clinical work. In the first survey, clinicians were asked to state their single most important characteristic of a user-friendly/user-unfriendly HIS; the predefined selectable characteristics were an “easy-/difficult-to-use interface”, a “simple/complex visual design”, a “short/long response time”, “good/poor data quality” and “rapid/slow retrieval of relevant clinical data”. In the second survey, clinicians were asked to further divide the most frequently mentioned characteristic of a user-friendly HIS from the first survey into relevant subcategories (multiple answers possible). The predefined selectable subcategories were the “availability of strong search tools”, a “simple software architecture”, the “presence of only few interface layers”, an “automatic alerting system”, an “overview of important clinical data in one window” and “prioritisation of data within the HIS”. Of note, free boxes and text fields allowed the clinicians to easily make comments and add further characteristics/subcategories in both surveys. Clinicians were not forced to answer specific survey questions in order to increase the participation rate.
No formal ethical approval was necessary for this study as it was part of internal quality improvement measures based on anonymised data.
The response rates for the first and second survey were 48.2% (40/83 clinicians) and 39.8% (33/83), respectively. The main characteristics of clinicians responding to the first survey are presented in table 1. In the first survey, the most frequently mentioned characteristics of a user-friendly HIS (table 2) were “rapid retrieval of relevant clinical data” in 47.5% (19/40), an “easy-to-use interface” in 15.0% (6/40) and a “simple visual design” in 15.0% (6/40). The basic characteristics of a user-unfriendly HIS are presented in table 3. There were no free-text responses in the first survey in regard to HISs in general.
In the second survey, clinicians divided the most frequently mentioned characteristic of a user-friendly HIS, “rapid retrieval of relevant clinical data”, into several subcategories including one free text response, which was “ability to maximise text windows” (table 4).
|Table 1: Main characteristics of clinicians responding to the first survey.|
|Characteristics||Number of clinicians (%)Total n = 40|
|20–29 years||10 (25.0)|
|30–39 years||23 (57.5)|
|>39 years||7 (17.5)|
|Board-certified specialist||9 (22.5)|
|Senior board-certified specialist||3 (7.5)|
|Table 2: Main characteristics of user-friendly hospital information systems.|
|Characteristics||Number of clinicians (%)Total n = 40|
|Rapid retrieval of relevant clinical data||19 (47.5)|
|Easy-to-use interface||6 (15.0)|
|Simple visual design||6 (15.0)|
|Short response time||3 (7.5)|
|Good data quality||1 (2.5)|
|Missing answer||5 (12.5)|
|Table 3: Main characteristics of user-unfriendly hospital information systems.|
|Characteristics||Number of clinicians (%)Total n = 40|
|Slow retrieval of relevant clinical data||24 (60.0)|
|Difficult-to-use interface||5 (12.5)|
|Complex visual design||6 (15.0)|
|Long response time||3 (7.5)|
|Poor data quality||0 (0)|
|Missing answer||2 (5.0)|
|Table 4: Rapid retrieval of relevant clinical data: subcategories.|
|Subcategories||Number of clinicians (%)Total N = 33|
|Simple software architecture||32 (97.0)|
|Strong search tools||31 (93.9)|
|Presence of only few interface layers||24 (72.7)|
|Automatic alerting system||21 (63.6)|
|Overview of important clinical data in one window||18 (54.5)|
|Prioritization of data||9 (27.3)|
|Ability to maximise text windows||1 (3.0)|
|Missing answer||0 (0)|
|Clinicians were asked to further divide the most frequently mentioned characteristic of user-friendly hospital information systems into relevant subcategories (multiple answers possible). The question was: What do you need for rapid retrieval of clinical data in hospital information systems (multiple answers possible)?|
With this cross-sectional survey we describe important characteristics of a user-friendly HIS from an end-user’s perspective. Our findings suggest that a simple and easy-to-use (i.e., intuitive or learnable) HIS interface is of major importance to clinicians with the ultimate goal of rapidly finding relevant patient data. Furthermore, an intuitive HIS may markedly reduce the expense of training new staff.
The absence of good user interfaces has been long recognised as a major barrier to the acceptance of HISs . Unfortunately, only few studies analysed the key factors for building usable and intuitive HIS interfaces . Considering the fact that the best predictor of clinicians’ satisfaction with an HIS is the perceived usefulness of the system , more studies should focus on the end-users’ needs. A Finnish cross-sectional study in 3929 clinicians actively working in patient care has shown that end-users of different HISs suffer from poor usability in mainly two usability dimensions: (i) compatibility between the HIS and clinicians’ tasks and (ii) HIS support for information exchange, communication and collaboration in clinical work . In contrast to our study, the Finnish survey was a nationwide evaluation of different HISs that was not designed to define the most important characteristics of a user-friendly HIS.
Various studies assessed the usability of HISs with a focus on mostly technical aspects (e.g., processing speed, system reliability), but did not specifically address the needs of clinicians [15, 16, 18–20]. In line with the results of our study, user satisfaction with HISs has been shown to be highly correlated with screen design and layout, and not primarily with most of the technical aspects of HISs (e.g., system speed) . In contrast to these observations, the speed of an HIS has been repeatedly shown to be one of the most important qualities for end-users .
Our study has several strengths. First, it was performed in a population consisting of clinicians who work with various HISs on a daily basis. Second, it is one of the first studies that described important characteristics of a user-friendly HIS from an end-user’s perspective. Nonetheless, our study has limitations. First, our survey may be not representative as it included a relatively small population from a single centre and as only clinicians from the Department of Internal Medicine were approached. Second, the surveys we used had not been validated and their characteristics had not been clearly defined in advance. Third, we partly selected predefined questions, which could have biased the results of our survey. Fourth, the response rate was relatively low with less than 50%.
In conclusion, the clinicians’ top priority in regard to an HIS was to quickly find relevant patient information. Developers of HISs should particularly focus on creating intuitive interfaces with efficient search engines and clear visualisation of clinical data.
No potential conflict of interest relevant to this article was reported.
PD Dr Balthasar L. Hug, MBA, MPH
Chief Medical Information Officer
Department of Internal Medicine
University Hospital Basel
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