An optimal human computer interface is essential for successful implementation and maximum benefit of the electronic health record (EHR). Human factors is the "scientific discipline concerned with the understanding of interactions among humans and other elements within a system" (Human Factors and Ergonomics Society, 2014). Human factors research can promote understanding of the nurse and EHR interaction. One aspect of human factors is usability; the ease of use or the quality of a user's experience with a product or a system. Usability includes design, interaction, and evaluation of human use of technology in particular contexts, such as the EHR. The goals are:

* Effectiveness: accuracy, can complete expected tasks, prevent use errors, promote safety

* Efficiency: productivity, time to complete tasks, time and ease of learning and maintaining skill, costs of training and modifications

* Satisfaction: agreeable to users, user perception of effectiveness and efficiency

Without good EHR usability, nurses will develop workarounds and encounter unintended consequences.

Heuristic evaluation is a type of study used to identify usability problems. The heuristic evaluation method is experience-based problem solving, in a somewhat trial-and-error fashion. Representative users (nurses) called evaluators are recruited to perform representative tasks (relevant work or device such as EHR documentation). The experimenter (observer) watches what the evaluators do with the task, where they succeed or experience difficulty, and listen to the evaluator talk while performing. Usability testing is done individually, one evaluator at a time, lasting about an hour, with about five evaluators. Testing usually begins early in the design process, with design revisions after each evaluator (because different evaluators find different problems), and results in a final design. Sometimes usability evaluation is done with a live product in use.

Evaluation is guided by usability heuristic principles, an established set of common properties of human-system interfaces such as: consistency in screen layouts, terminology consistent with real world, minimalist without unnecessary clicks, and prevents users from making errors (Harrington, Porch, Acosta, & Wilkens, 2011; Nielson, 1995a). Evaluation summarizes the usability problems, or violations of heuristic principles. Each problem is then assigned a severity rating of 0 to 4 by the evaluators (Nielson, 1995b):

0. No usability problem

1. Cosmetic problem that does not need fixing unless time is available

2. Minor problem and fixing is a low priority

3. Major problem and fixing is a high priority

4. A usability catastrophe that needs fixing before continuing

Nurses in one hospital conducted a live environment heuristic evaluation usability study of their EHR interface after implementation, because of user dissatisfaction (Harrington et al., 2011). Nurse evaluators considered documentation tasks and identified the problem locations, descriptions, and principles violated, assigned severity ratings, and suggested solutions. The researchers identified a (not uncommon) heuristic violation of duplicate and inconsistent documentation. Skin color was documented in two locations, with different formats, and different adjectives for skin color. Documentation duplications and inconsistencies result in poor usability that can impact effectiveness (interfere with accurate data extraction for monitoring and reporting, promote assessment errors), efficiency (slow the process of learning and completing documentation), and satisfaction (frustration with inconsistencies and redundancy).

Although evaluations are generally done before implementation, a usability study of an implemented EHR can optimize benefits. Nurses are the major users of hospital EHRs and need to participate in usability evaluation.

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