Visual displays present information to users in various forms, including text, numbers, graphs, maps, diagrams, and pictures.1 Effectively designed visual displays allow users to extract important information and view and understand patterns in data to accomplish a specific goal. Visual displays are not always safety-critical, but in high-risk industries like healthcare, automotive, aviation, and nuclear, visual displays play a central role in data comprehension, reasoning, communication, and decision-making.2,3
Health information technologies (health IT), specifically electronic health records (EHRs), are used by most healthcare facilities in the United States and this technology relies on visual displays to communicate information to users. Health IT visual displays convey information such as patient identifiers, patient history, lab and imaging results, provider notes, medication information, and ancillary content like site policies and drug interaction data.4,5
An effective visual display helps providers accurately interpret patients’ health data, an essential aspect of providing quality care. Unfortunately, EHR visual displays have been suboptimal partially because of the amount, complexity, and diversity of information that needs to be represented.6 Studies have shown that the visibility of data, defined as where information is located and how it is presented, is a common problem in electronic medication administration records (eMARs) and computerized provider order entry (CPOE) systems.7–11 The consequences of poor visual display are profound. When visual displays are ineffectively designed, they can lead to clinician burnout,12–15 diagnostic error,5,16,17 and even patient harm.7,11,18
Human factors is a scientific discipline that aims to understand human capabilities to design work environments that meet these capabilities and enable optimal human performance.1 From a human factors perspective, designing an effective visual display requires considering the purpose of the visual display and the information that needs to be conveyed through the display, as well as the strengths and limitations of human perception. For example, we can perceive a limited portion of the light spectrum (i.e., 380 to 700 nanometers) and cannot see information in the visual display if it is below human detectability levels. Nevertheless, our perception allows us to find patterns and identify meaning in the abstract (e.g., we connect red with the meaning “stop” and “emergency”).19 These features of human perception, both the ways it hinders and helps us interpret the world, can be understood and leveraged to make effective visual displays.
Many high-risk industries other than healthcare have historically incorporated human factors into their visual display designs by developing guidelines for optimal use. However, there are no required human factors guidelines or standards for the design of EHR visual displays. Consequently, EHR vendors and healthcare facilities may create and use design principles that may not adhere to human factors principles. There are EHR design recommendations from different agencies, including the National Institute of Standards and Technology (NIST). However, these are not required and often not adhered to.20
In this study, we sought to identify visual display guidelines used in the automotive, aviation, and nuclear industries to inform healthcare practices. If adopted in healthcare, these guidelines may address the plethora of visual display issues in EHR design and safety. Human factors and clinical experts reviewed the automotive, aviation, and nuclear industry guidelines to identify those most relevant to EHRs. Based on these guidelines, we provide considerations for visual display design in the EHR.
Previously described in Pruitt et al.,21 human factors guidelines documents endorsed by United States–based oversight agencies (e.g., Federal Aviation Administration) were identified for automotive, aviation, and nuclear industries. Two human factors experts evaluated the documents for inclusion based on the following four criteria: the publication must be endorsed by a federal government agency or be recognized by a federal government agency as applying to the industry for which the agency has oversight; be related to the automotive, aviation, or nuclear industry; contain principles, guidelines, and/or standards related to visual displays; and have been published after January 2012. Each reviewer independently evaluated each document to assess whether the document met inclusion criteria, and then each document was jointly discussed to ensure agreement. Through this process, we identified one comprehensive document from each industry for analysis in this study.22–24
A human factors expert extracted the title, date, agency, and specific discrete guidelines from each of the three industry documents included in the review and populated a Microsoft Excel spreadsheet. Guidelines were included if they contained information about the visual display, regardless of whether they were directly applicable to healthcare. Following extraction, two human factors experts and one clinical expert reviewed the guidelines to assess whether they were relevant to either inpatient or outpatient EHR design, including eMAR and CPOE, for frontline staff. Quality metrics in the EHR, such as sepsis rates for leadership or administration and demographics information, were not considered when determining relevance. Disagreements between experts were discussed until a consensus was reached. The guidelines that were relevant to healthcare were included in the full analysis.
The EHR-relevant guidelines were reviewed and grouped into meaningful topics. These topics were identified using a modified reflexive thematic analysis.25,26 Two human factors experts familiar with the data independently reviewed a subset of the relevant guidelines and assigned a label to each to represent the overall topic. Labels were discussed and collated to create an initial set of common topics that applied to the guidelines reviewed by all three industries. Using these inductively generated topics, the human factors experts independently classified the remaining guidelines, modifying topics as necessary and discussing discrepancies until a consensus was reached. Topics were reviewed for internal consistency and refined as necessary. The final topics and definitions can be found in Table 1.
From the relevant guidelines under each topic, a clinical expert identified three guidelines per topic that were deemed to be the most relevant to the visual display of EHR design, considerations for healthcare, and examples.
A total of 449 guidelines were extracted from the industry documents and 283 (63.0%) were deemed relevant to EHRs. By industry, 12 of 44 (27.3%) automotive industry guidelines were relevant, 43 of 115 (37.4%) aviation industry guidelines were relevant, and 228 of 290 (78.6%) nuclear industry guidelines were relevant. A comprehensive list of all the relevant guidelines can be found in Online Supplement Appendix A. Table 2 describes guidelines highly relevant and applicable to EHR design from other high-risk industries, considerations for EHRs, and examples per visual display guideline topic.
Our analysis identified visual display guidelines, organized around six different topics, from the automotive, aviation, and nuclear industries to inform EHR design. Of note, there were far more EHR-applicable guidelines from the nuclear industry than from the aviation and automotive industries. The quantity of EHR-relevant nuclear guidelines may be due to similarities in the purpose of information displays in nuclear and healthcare compared to aviation and automotive. In both the nuclear and healthcare industries, displays may be used by several users with different roles and responsibilities (e.g., engineers and control room operators in nuclear and physicians and nurses in healthcare), while in the aviation and automotive industries, the visual displays are typically designed for a single user profile (e.g., a pilot or a driver).
Many cross-industry guidelines address EHR usability and safety issues experienced by frontline clinicians and described in the literature.7–9,11,27 The final guidelines provide insights that may inform EHR design and optimization to improve patient safety. The guidelines apply to multiple stakeholders, including EHR vendors, healthcare facilities, and policymakers.
Implications for EHR Vendors and Healthcare Facilities
There are several opportunities for EHR vendors and healthcare facilities to leverage these visual display guidelines to improve the usability and safety of EHRs. EHR vendors can use these guidelines to inform their design and development process. Specifically, EHR vendors can update current design standards or create new design standards that adhere to these guidelines. Updated designs would improve the EHR visual displays provided to customers since their product designers would use design standards informed by human factors principles. In addition, EHR vendors can develop test case scenarios based on these guidelines to evaluate EHR visual displays during their usability testing. Test case–based usability testing would help identify possible usability and safety issues before the EHR is used in the clinical environment.
Healthcare facilities can use these guidelines to evaluate the usability and safety of EHR visual displays when considering a new EHR product. The guidelines can also be applied to optimize currently used EHRs. Many EHRs are configured and customized by healthcare facilities, and these processes give rise to the visual display that frontline clinicians use. Previous research has shown tremendous variation in the same EHR vendor product across different healthcare facilities because of configuration and customization decisions, and these variations are associated with different task completion times and error rates.8,9 The guidelines can be used by healthcare facility EHR experts to inform their customization and configuration decisions. Further, high-risk functions in the EHR can be evaluated by examining the visual display elements when using those functions to ensure the display adheres to the guidelines presented here. When specific functions and/or features not aligned with the cross-industry human factors guidelines are identified, facilities can work with their EHR experts to determine whether they can customize or configure their EHR to meet the guidelines. If they cannot make the appropriate changes, healthcare facilities can work with their EHR vendor to make improvements.
In addition to using these guidelines, there are several other resources for healthcare facilities to assess and improve the safety of their EHR. These resources include several self-assessment tools28–32 and test cases for EHR usability evaluation.33,34
Implications for Policymakers
Identifying cross-industry guidelines relevant to EHR visual displays also has policy implications. Currently, the Office of the National Coordinator for Health Information Technology (ONC), the federal agency that oversees EHRs, does require that EHR vendors follow specific design standards. The ONC requires EHR vendors to perform usability testing for certain EHR functions. There is an opportunity for the ONC to develop required usability test cases that embed these guidelines in the test cases. Test case development would promote EHR vendor adoption of these safety-critical human factors principles. The ONC could also include these guidelines as part of their real-world testing requirements focused on assessing EHR vendor products in actual clinical environments. Finally, the ONC could work with NIST to develop EHR-specific design guidelines or standards to inform EHR vendor practices.
Aviation, automotive, and nuclear industry guidelines were identified through an internet search. We may have missed alternate industry guidelines or more recent versions in a private domain. We used qualitative assessment to identify which guidelines are relevant to EHR visual displays. Therefore, some guidelines marked as relevant may be irrelevant, and conversely, some guidelines marked as irrelevant may be relevant.
Future research should consider the applicability of these guidelines to other healthcare software, such as patient portals. Despite being essential to effective patient care, many non-EHR software are neglected in human factors research. Additionally, future research should investigate how guidelines in other industries compare to the guidelines currently outlined in healthcare.
Poor EHR usability has consequences for patient safety and clinician burnout. Relevant visual display design guidelines from other high-risk industries—aviation, automotive, and nuclear—were identified to inform safe and efficient EHR design. These guidelines can be used by EHR vendors, healthcare facilities, and policymakers to improve the usability and safety of EHR visual displays.
The authors declare that they have no relevant or material financial interests.
About the Authors
Zoe Pruitt (Zoe.M.Pruitt@medstar.net) is a human factors scientist at the MedStar Health National Center for Human Factors in Healthcare.
Jessica Howe is the associate director of operations at the MedStar Health National Center for Human Factors in Healthcare.
Lucy Bocknek is a human factors and safety scientist at the MedStar Health National Center for Human Factors in Healthcare.
Arianna Milicia is a senior research associate at the MedStar Health National Center for Human Factors in Healthcare.
Patricia Spaar is a senior clinical safety and research specialist at the MedStar Health National Center for Human Factors in Healthcare.
Seth Krevat is the senior medical director at the MedStar Health National Center for Human Factors in Healthcare and an assistant professor at Georgetown University School of Medicine.
Raj Ratwani is the director of the MedStar Health National Center for Human Factors in Healthcare, vice president of scientific affairs at the MedStar Health Research Institute, and an associate professor at Georgetown University School of Medicine.