HIMSS: How many EHR mouse clicks make a visit inefficient?

NEW ORLEANS—A hierarchical task analysis of EHR use looked at component usage, non-verbal communication, verbal analysis and time-at-task profiling. Alan Calvitti, PhD, data visualization expert worked with the VA’s San Diego Healthcare System, presented the results of the project during an educational session at the Health Information and Management Systems Society (HIMSS) annual convention.

The study involved a fixed computer and an exam room camera that tracked nonverbal communication, clinical workflow and verbal communication. Usability software tracked mouse activity and EHR screen recording.

Out of the 126 patient visits studied, physicians shared EHR components only 25 percent of the time.

The major categories of user-EHR interactions were information retrieval, documentation, order entry and coordination. “Visits are very busy,” said Calvitti. “There is a lot of talking by both the patient and the provider and lot of back and forth by the physician between computer activity, including the physical exam.”

A review of more than 22,000 mouse clicks revealed that the physicians studied spent 40 percent of their time in the notes component, 27 percent doing order entry and 10 percent on both medications and labs. To improve efficiency, “we want to concentrate on the largest slices of the pie” which he can do either at the physician or visit level.

For example, when looking at just time spent in the notes component of the EHR, Calvitti said 83 percent of the time the physicians were looking at the current note. “Very little activity consists of seeing what’s in previous notes or notes by other providers.” It’s possible that the physicians prefilled some of that information at some point before the patient encounter, however. If not, that could be a measure of inefficiency because “information in the record might go unused. It could be old information but very important information.”

Looking more generally at the patient visits studied, 40 percent of those visits the physician spent looking at the computer and 24 percent of the time he or she was looking at the patient. The longer the visit, the more gaze to the EHR, he said.

Clearly, the physicians use notes as the central hub for computer workflow, Calvitti said. They were most likely to share the labs screen (45 percent), medications screen (24 percent) and notes screen (14 percent). While labs and medications are objective, “notes might have information [the patients] may or may not agree with.”

Calvitti also studied order entry for medications. One physician took 165 mouse clicks to order six medications. “Sometimes there is a very complicated tree to go through.” Other medications required just nine mouse clicks. “We can use that information to focus on which ones are more involved to see if we can improve efficiency.”

The healthcare system plans to leverage the study results to drive EHR redesign, Calvitti said. For example, unstructured ASCII files make it difficult to search information. Minimizing pull-down lists and navigation burdens would save time. “We need to develop tools to help them visualize data that already exists.” For example, some patients have 10 years worth of lab results but it takes a lot mouse clicks to go through them.”

Doctors also have to integrate a lot of information to do any order entry. With different components on separate screens, perhaps the use of two monitors would be helpful.