Human Factors of Health Information Technology—Challenges and Opportunities

Health information technologies are becoming ubiquitous. According to the DHHS Office of the National Coordinator for Health Information Technology, 96% of nonfederal acute care hospitals had adopted certified EHR (electronic health record) technology by 2015, up from 71.9% in 2011 (Henry, Pylypchuk, Searcy, & Patel, 2016). Adoption of basic EHR technology rose from 9.4% to 83.8% between 2008 and 2015 (Henry et al., 2016), and personal health records (PHR) technology adoption will exceed 75% by 2020 (Ford, Hesse, & Huerta, 2016). Health information technologies are changing healthcare delivery, transforming relationships between patients, caregivers, and clinicians, and offering unique opportunities to achieve the Quadruple Aim of individual care experience, population health, healthcare cost control, and clinician quality of working life (Sikka, Morath, & Leape, 2015). As health information technology becomes pervasive, issues of appropriate design and implementation have emerged as special challenges (Institute of Medicine, 2012; Karsh, 2004; Karsh, Weinger, Abbott, & Wears, 2010); this is an area of contribution for the concepts and methods of human factors engineering. This special issue presents state-of-the-art research on human factors of health IT with eight articles that identify and address various human factor aspects of health IT. These eight articles examine multiple technologies and user groups and describe how health IT can support care that is highly distributed over time, space, and boundaries. The articles also make it clear that a systems approach to health IT design and implementation is critical for positive outcomes for all stakeholders. Finally, the eight articles show the impact of human-centered methods for the design and implementation of health IT.

New and Varied Technologies—New Opportunities

According to the Office of the National Coordinator for Health IT, “The term ‘health information technology’ (health IT) is a broad concept that encompasses an array of technologies to store, share, and analyze health information” (https://www.healthit.gov/patients-families/basics-health-it). Health information technologies include EHRs, PHRs (including patient portals), e-prescribing technologies, and health information exchange. Not only healthcare providers but also lay people, patients, and their caregivers use health IT. In this special issue, research examines new forms of health IT used by clinicians and patients. For instance, on the clinician side, Asan, Flynn, Azam, and Scanlon (2017) examined pediatric ICU nurses’ perceptions of a large customizable interactive monitor. Alyousef and colleagues (2017) described various health information technologies used by care managers and the challenges associated with these multiple technologies when coordinating care for chronically ill patients. The articles by Doggett, Weiler, and Saleem (2017) and Ozok, Wu, and Gurses (2017) assessed usability and other design characteristics of PHRs used by lay people, including college students. In this special issue, three articles address primarily clinicians (Asan et al., 2017; Alyousef et al., 2017; Hundt, Adams, & Carayon, 2017), four articles address primarily patients (Doggett et al., 2017; Ozok et al., 2017; Valdez & Brennan, 2017; Srinivas, Cornet, & Holden, 2017), and one article examines the perspectives of both clinicians and patients (Martinez et al.). Future research needs to address the range of users (health-care professionals and lay people) of health information technologies.

A recent study introduced the terminology of clinical, collaborative, and consumer technologies (Valdez, Holden, Novak, & Veinot, 2015). Future research is critically needed to further understand patients as users of health IT, especially in the context of collaborative and consumer technologies. Several articles in this special issue examine various groups of patients, such as elderly patients with heart failure (Srinivas et al., 2017). As technologies continue to develop in the form of, e.g., smart applications, wearables, and sensors, we need to further develop human factors concepts and methods to ensure that these technologies fit user needs and are integrated with healthcare processes.

Health information technologies provide opportunities to not only enhance tasks and processes of individual user groups but also to transform the relationship between health-care providers and patients (Walker & Carayon, 2009). The study by Asan and colleagues (2017) shows how a large customizable interactive monitor used in a pediatric ICU can facilitate clinician/family communication and support family-centered care and family engagement and empowerment. The study by Martinez and colleagues (2017) shows the benefit of a well-designed consumer health informatics application to enhance collaboration between patients and clinicians and, subsequently, improve blood pressure control. Future research should further explore how health IT can be used to support the collaborative work between clinicians and patients (Holden et al., 2013).

Collaboration between clinicians and patients often implies care that is highly and variably distributed over time, space, and organizational boundaries. This can create a range of challenges for health IT users, especially as patient-related information may not be easily accessible or available as demonstrated by Alyousef and colleagues (2017). Future research needs to develop concepts and methods for designing health IT that can support distributed care processes.

Need for Systems Approach in the Design and Implementation of Health IT

Articles in this special issue clearly highlight the need for a systems approach in health IT design and implementation. Several studies use the original SEIPS (Systems Engineering Initiative for Patient Safety) model (Carayon et al., 2006) or the SEIPS 2.0 model (Holden et al., 2013). For instance, Alyousef and colleagues (2017) used the SEIPS model to describe and quantify health IT-related obstacles experienced by care managers. Martinez and colleagues (2017) applied the SEIPS 2.0 model to examine the range of system variables that influence the experience of patients and clinicians with a consumer health IT application for blood pressure monitoring and management. Like a few other studies in the special issue (e.g., Doggett et al., 2017), this study shows the importance of usability, but it also demonstrates that usability is not sufficient. Other system factors are critical to ensure that technologies support effective, efficient, and safe care processes. Martinez and colleagues (2017) show that the sociotechnical system needs to support collaboration among patients and care team members.

Using a systems approach allows researchers to uncover issues of importance in the design and implementation of health IT. For instance, the studies by Martinez and colleagues (2017) and Srinivas and colleagues (2017) emphasize the critical role of health IT to support and enhance patient self-management. The study by Ozok and colleagues (2017) describe how PHRs should be designed to support personal health information management. Future research should further develop system-based methods for the design of health IT. It is not just about the technology; we need to pay attention to the entire system, i.e., the sociotechnical system, in which the technology is used. This poses methodological and practical challenges, especially when looking at technologies used in nontraditional work environments, e.g., home and community settings (Holden, McDougald Scott, Hoonakker, Hundt, & Carayon, 2015).

Understanding the person at the center of the sociotechnical system is key to good design and implementation of health IT that helps users and support tasks and processes. In this special issue, Valdez and Brennan (2017) help us to understand the cultural dimension of sociotechnical systems. Their research highlights the need to go beyond simplistic conceptualization of culture. Patients often describe their multiple, varied cultural identities; therefore, challenging the approach in which a technology is designed for a specific cultural group. In addition, Valdez and Brennan (2017) describe the various ways that culture influences users and their interaction with technology. This type of research provides important direction for human factors design of health IT that is culturally informed. Future research should extend this line of research and better define how culture can be incorporated as part of the complex sociotechnical system.

Human-centered Design Can Make a Difference

The discipline of human factors needs to demonstrate not only that it can identify problems, but also that it provides value to design and implementation processes and that it can improve care processes and outcomes (Xie & Carayon, 2015). Two articles in this special issue are particularly important as they demonstrate the value of human-centered design. Srinivas and colleagues (2017) describe a multiphase approach for the design of consumer health IT for elderly patients with heart failure. The multiphase approach incorporates multiple data collection methods, systematic usability evaluation, and user feedback. Hundt and colleagues (2017) describe the CUE (collaborative usability evaluation) model and its implementation and sustainability in a healthcare delivery organization. Based on participatory ergonomics (Haims & Carayon, 1998; Haines, Wilson, Vink, & Koningsveld, 2002), the CUE model describes a process for integrating systematic usability evaluation in health IT design and implementation processes of healthcare delivery organizations. Hundt and colleagues (2017) emphasize the importance of feedback and ongoing learning, and organizational leadership as key contributors to the successful implementation of the CUE model.

Human-centered design can make a difference, but it is hard work and it comes with challenges. See, for example, the article by Srinivas and colleagues (2017) that describes various methodological and practical challenges. Future research should further develop human factors methods and approaches that can be adopted and adapted by designers and implementers of health information technologies. This remains an important research challenge (Ratwani, Fairbanks, Hettinger, & Benda, 2015).

Conclusion

In conclusion, as information technologies become a critical tool in health-care transformation, human factors engineering holds promise for supporting and identifying health IT users’ needs for the optimal design of these technologies. Using multiple human factors methodologies, studies in this special issue describe complex interactions between various health information technologies and their users. As information technologies continue to develop, we need to further develop human factors concepts and methods to ensure that health information technologies are designed for humans, support user needs, and are integrated with health-care processes.

Acknowledgments

We would like to thank Professor Gavriel Salvendy for trusting us to organize this special issue. We also thank Professor Constantine Stephanidis and the staff at the International Journal of Human–Computer Interaction for their support.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or AHRQ.

We would like to thank all of the reviewers who have provided important feedback and helped to increase the quality and impact of the published articles.

Funding

This research was partly supported by the Clinical and Translational Science Award (CTSA) program, National Center for Advancing Translational Sciences (NCATS), grant number UL1TR000427. In addition, the research was supported by the Agency for Healthcare Research and Quality (grant number 1R21HS023626-01).

Additional information

Funding

This research was partly supported by the Clinical and Translational Science Award (CTSA) program, National Center for Advancing Translational Sciences (NCATS), grant number UL1TR000427. In addition, the research was supported by the Agency for Healthcare Research and Quality (grant number 1R21HS023626-01).