Transferring tasks from paper to electronic systems always brings a few unexpected surprises. Despite the best efforts of analysts and software designers, it is often difficult to capture all the nuances of any human activity, no matter how seemingly simple, within the confines of an electronic system. Future users, being unaware of all of the things they do when completing a task, can only contribute so much to the requirements gathering process—they don’t know what it is they don’t know. The more complex the processes and tasks involved, the greater the number of unknowns that are likely to be missed. Flanagan, et. al., have done an excellent job of revealing a few of these unknowns for EHR designers.
In Paper- and Computer-based Workarounds to Electronic Health Record Use at Three Benchmark Institutions, the authors describe 11 types of workarounds to EHR use at three sites that use different EHR systems. Workarounds (which may be paper or computer-based) were further categorized by the number of institutions where they were observed. Of the three workarounds observed at all sites, one of them, memory, seems to be a perfect example of the type of unknown that can easily slip by during requirements and design phases.
Memory workarounds involve the use of various cues to keep on top of things. In discussing their findings, the authors note:
Likewise, in situations where there are many complex tasks and patients, constructing memory cues for completing work is necessary. These types of memory cues are examples of prospective memory aids which serve as a prompt to complete a task in the future. Work settings that require multi-tasking and are characterized by frequent interruptions and distractions carry a particularly high load for prospective memory.
Prospective memory is something we make use of without giving it much thought. I stack paper mail in order of importance for reply purposes. Particularly important dates are circled in red on my office wall calendar months in advance, though, lately, I have moved somewhat to my iPhone reminder app. However, I still find the wall calendar more helpful, although I cannot put my finger on why.
According to Tidwell in Designing Interfaces, 2nd Edition, prospective memory has yet to catch on as an interface feature. She states:
Prospective memory is a well-known phenomenon in psychology that doesn’t seem to have gained much traction yet in interface design. But I think it should.
Having adequate documentation of the existence of prospective memory workarounds in EHR use is a good start to addressing the problem. There are a few seemingly obvious solutions—electronic sticky notes come to mind. However, as with most things, reproducing the utility of sticky notes in electronic form is not as simple as it appears. For one, paper notes are eminently portable. They can be attached to nearly anything and require no log-on to review (which is one reason I think the wall calendar is winning over my iPhone). When multitasking, good reminders have to persist across tasks and locations. Mobile applications could help with this by making To Do lists portable.
As the authors note, the amount of physical movement and the number of context switches that occur in clinical environments have to be accounted for in e-prospective memory solutions. Anyone working in a clinical setting is interrupted many times each day. Further, patient care doesn’t end just because the patient is not physically present. Ideas for diagnostic workups and treatment changes happen 24/7. As long as clinicians are awake, they are usually thinking about some aspect of patient care. How can this free-style thinking be supported by EHR features in a manner that will not require a three-hour training class?
Ms. Tidwell suggests that the key is flexibility. That is, giving users the ability to create their own reminder systems by providing tools that are simple to use and easy to learn. Who could disagree? But, of course, the devil is in the details.
I like OneNote a lot; I use it constantly. My use of OneNote was not the result of a needs assessment. I read a blurb about it and, since it was already installed on my laptop, I opened it up to see what it did. Within three days, I stopped keeping ideas and plans on paper and haven’t looked back since. After having written everything in notebooks my entire life, now writing things on paper seems too restrictive – you can’t hyperlink to paper.
OneNote (or Evernote) seems to have many of the required features for prospective memory support, and it is dirt simple to use. Would something like these two applications, but with API-based EHR access and with full HIPAA security features, peer-to-peer sharing, mobile access , and a full set of alerting functions, solve the prospective memory conundrums of busy providers? Who knows, but it’s an intriguing idea.
In terms of electronic systems supporting clinical work, the obvious initial strategy, back when we had 80-column green screens, was to make electronic systems look like their paper cousins. That worked, to a certain extent, but not without causing a different set of problems.
Daily, we are learning that there is more to using paper than meets the eye, and that clinical work involves many more cognitive tasks than we realize. For EHR architects, this means a lot more time spent observing users in addition to typical requirements-gathering activities. Because, information-wise, asking potential users to describe all the nuances of a complex clinical task is about the same as asking them how they can walk and chew gum at the same time–knowing how to do it is not the same as knowing how it’s done…