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As many evaluations show, healthcare organizations do not accomplish the intended effects of their eHealth systems due to inadequate usability. On behalf of the Swedish Ministry of Health and Social Affairs, the usability of current eHealth systems in Swedish healthcare have been analysed from the perspective of healthcare and social service professionals. The objective of the study was to report on current problems, potential solutions as well as to relate these to research in relevant areas. Using a participatory approach, seven workshops were held where researchers within health informatics collaborated with staff from different care providers, representatives of the national associations of health and social care professionals and the national eHealth system vendor organization. This paper presents a foundation for further development of eHealth systems, condensed into 10 issues that the Swedish health and social care professionals find imperative to improve. The study emphasizes that the development of eHealth systems is always a matter of organizational and process development and must be integrated into the care practice improvement process. Further, based on the findings, some identified challenges are discussed.
Disturbing or Facilitating?
On the Usability of Swedish eHealth
Systems 2013
Isabella SCANDURRAa,1 Maria HÄGGLUND b, Anne PERSSON c and
Rose-Mharie ÅHLFELDT c
Uppsala University, Department of Information Technology
Karolinska Institutet, Health Informatics Centre
c University of Skövde, School of Informatics
Abstract. As many evaluations show, healthcare organizations do not accomplish
the intended effects of their eHealth systems due to inadequate usability. On behalf
of the Swedish Ministry of Health and Social Affairs, the usability of current
eHealth systems in Swedish healthcare have been analysed from the perspective of
healthcare and social service professionals. The objective of the study was to
report on current problems, potential solutions as well as to relate these to research
in relevant areas. Using a participatory approach, seven workshops were held
where researchers within health informatics collaborated with staff from different
care providers, representatives of the national associations of health and social care
professionals and the national eHealth system vendor organization. This paper
presents a foundation for further development of eHealth systems, condensed into
10 issues that the Swedish health and social care professionals find imperative to
improve. The study emphasizes that the development of eHealth systems is always
a matter of organizational and process development and must be integrated into the
care practice improvement process. Further, based on the findings, some identified
challenges are discussed.
Keywords. eHealth systems, user participation, Participatory design, healthcare
and welfare development, evaluation, validation, usability, patient-centricity.
eHealth systems, i.e. information technology (IT) applied in the health and social care
sector, has great potential to enhance efficiency, improve quality of life and strengthen
innovativeness in health and social care. Extensive resources are currently being
invested in eHealth development at local, regional and national levels of society. To
achieve the maximum benefits from these investments, eHealth systems that really
support health and social care professionals in their work, focusing on health as an
effect of the care and treatment given, are required. However, technology is in health
and social care often regarded as a barrier to providing good healthcare in an efficient
way [1]. Specifically, insufficient usability of the systems is identified as a major
obstacle [1,2,3]. Unfortunately, little effort is put into health information system
1 Corresponding Author: Isabella Scandurra, e-mail:
e-Health – For Continuity of Care
C. Lovis et al. (Eds.)
© 2014 European Federation for Medical Informatics and IOS Press.
This article is published online with Open Access by IOS Press and distributed under the terms
of the Creative Commons Attribution Non-Commercial License.
development according to usability requirements and methodology, leading to
bottlenecks in eHealth systems when implemented into daily practice [3,5].
1. Background
The Swedish National Strategy for eHealth in Health and Social Care [6] identifies
useful and accessible information, as well as decision-making support for staff as
important priority areas. In a review (RiR 2011:19), the Swedish National Audit Office
concluded that the eHealth strategy has not been able to secure the benefits from the
efforts made. Current IT-systems do still not give health and social care professionals
access to “the right information at the right time” [7]. The Gartner report [2],
commissioned by the Ministry of Health and Social Affairs, indicated that
professionals primarily identified a need for improvement of the usability of eHealth
systems to increase their utilization. Based on the mentioned evaluations, the Swedish
Ministry of Health and Social Affairs acknowledged the need to address usability
issues in eHealth from a national perspective [5], which was the starting point for the
study presented in this paper; Usability of Swedish eHealth Systems 2013 (USeHS).
2. Method
The national associations of health and social care professionals carried out a joint
initiative in the autumn of 2012 to create the project financed by the Ministry of Health
and Social Affairs. The aim of the project was to collect and highlight lessons learned
and examples of best practice as a basis for improved integration of health and social
care providers and their IT support, as well as answering the following questions:
- Which problems do care professionals experience as users of eHealth systems? !
- Which solutions do they regard as being most important? !
- How do these findings relate to existing research regarding usability in eHealth? !
The concept of usability, according to the international standard for usability 9241-11,
focuses on a specific user in a specific context performing a specific task [4]. Therefore
it is challenging to address usability issues on an overall national level with the aim to
create national strategies. Therefore, such an initiative needs to be approached by a
bottom-up approach and by involving the real end-users [8].
The research approach of this work is based on three principles; user-centered
development, cross-organizational health and social care and real patient-centered
processes [8]. Hence, a participatory approach was adopted, inspired by the
Scandinavian tradition’ emphasizing participation in design [9,10,11]. The major
Swedish national associations of health and social care professionals were a driving
force and members (actual end-users) from each organization were involved from the
start of the study. In order to collect data, representatives of health and social care staff,
researchers in the area of usability in health informatics, and representatives of
suppliers of eHealth systems have participated in nine workshops [8]. In the first
workshop researchers, representatives from care profession organizations and the
ministry of health set the focus and aim for the following workshops. In workshops 2
and 3 end-users worked together with researchers to identify problems, and propose
potential solutions and future work scenarios. The fourth workshop involved vendors,
I. Scandurra et al. / Disturbing or Facilitating?222
while workshop 5-7 focused on discussing the results with other researchers and user
representatives throughout Sweden. Finally, in workshop 8 the results were prioritized
into an action list, and workshop 9 was an open workshop at a national eHealth
conference where more feedback and comments were gathered.
3. Results
As a first step, current eHealth usability problems were identified based on users
experiences. After that, potential solutions to the problems were proposed and
prioritized in the workshops as well as by representatives of eHealth systems vendors
and other Swedish eHealth researchers [5]. In this paper, the focus is not on describing
the problems but rather to emphasize what needs to be done in order to improve the
situation. Important actions to perform locally, in each healthcare organization, were
formulated, as well as suggestions for how to operationalize usability improvement
work from a national perspective. Further, examples of eHealth systems and services
with high usability for healthcare professionals were identified.
3.1. Ten priorities for improving usability
The development of eHealth systems is always a matter of organizational and process
development and must be integrated into the care practice improvement process. To
stress this, the USeHS study highlights the following ten priorities for improving
usability. Addressing them is imperative in order to capitalize on the potential of
eHealth systems.
1. eHealth systems must be managed, evaluated, supervised and continuously optimized in
relation to the usability needs of the organization that it is intended to support. There is
a need for more collaborative efforts to integrate work processes and eHealth systems
into a coherent and meaningful whole.
2. Increased participation of usability experts, health informatics specialists and users is
required in the development, implementation and evaluation of eHealth systems. Care
professionals must be involved in managing each eHealth project.
3. All health and social care professionals must have a basic understanding of the
opportunities offered by eHealth systems, as well as adequate knowledge of how the
eHealth systems should be used and how work processes relate to eHealth systems.
Training and enhancement of informatics skills must be prioritized in the education and
then continue in employment. Education in health informatics must be substantially
expanded and take into account sector-independent knowledge in the area of informatics
as well.
4. The technical prerequisites to document and access information must be met at the point
of care. The need is particularly great in the social care sector where access to technical
support is low and mobile work is common.
5. The technical infrastructure must be sufficiently powerful and reliable enough for users
to be able to rely on it. Security solutions must be implemented so that users can
perform their work without unnecessary interruptions. The systems must be developed
in order to ensure that response times are kept to a minimum. The IT environment is
becoming increasingly complex, partly as a consequence of increasing requirements for
exchange of information between health and social care providers. To manage this, care
providers must coordinate their organizations for the operation and administration of
eHealth systems more efficiently.
I. Scandurra et al. / Disturbing or Facilitating? 223
6. Health and social care staff must be able to move between different eHealth systems and
still be able to find vital information quickly in time-critical situations. This requires the
presentation of certain types of health and social care information to be structured and
standardized graphically, while still supporting personalization, based on e.g. role,
activity and situation.
7. Multiple recording of the same data must be eliminated. A set of information should be
recorded only once and communicated automatically in its existing or aggregated form
to other systems. The work on the National Interdisciplinary Terminology and the
National Information Structure as well as the implementation of automated transfer of
data must be accelerated.
8. Important information must follow the care recipient across health and social care
provider boundaries to facilitate person-centered health and social care. Unnecessary
legal obstacles must be eliminated. At the same time, eHealth systems must be
developed to support the enforcement of legal and ethical requirements when data flows
across health and social care provider boundaries.
9. Research on the usability of eHealth systems must be strengthened and the knowledge
applied in practice. More usable systems lead to improved capture and recording of data,
which in turn can provide improved feedback to the care staff and valid data for
10. eHealth skills are a strategic development resource that must be present at all levels of
management in health and social care. Understanding of usability is the key to achieve
benefits of eHealth systems, and essential for good and reliable health and social care.
4. Discussion and conclusion
Based on the findings, some of the challenges are discussed, both from the health and
social care sectorsas well as the researchers’ point of view.
The users stated that the eHealth systems of tomorrow must follow the work
processes much better. The systems must provide overview, take little time to
assimilate and navigate and give the user a sense of control. This is in blatant contrast
to the present situation, where the users need to add manual check-points in and
between systems, both in terms of information and documentation. The systems need to
be adjusted to the particular task in question and the circumstances in which it is
carried out. Multiple recording of the same information as well as constant log-ins and
log-outs are issues that must be prioritized and dealt with immediately [5]. In the health
and social care of municipalities, access to mobile and situationbased eHealth systems
and tools must improve substantially [12].
Usability in current eHealth systems must be improved to guarantee patient safety
and support a person-centered health and social care as well as optimal use of resources
[13]. The users point out that there is a need for digital tools and systems where the
information follows the care recipient across care provider boundaries and where the
presentation of information is adapted to the users’ professions, situations and previous
choices or preferences. Certain types of health and social care information must be
structured uniformly no matter which care provider is involved. E.g., standardized
support for medication management is needed in order to reduce the risk of errors in
the medication supply chain, and uniform access to vital information is necessary in
order to guarantee safe and timely decision-making in time-critical situations [14].
Based on the results achieved in USeHS, it is clear that the research about what is
required to improve the usability of eHealth systems needs to be increased in order to
I. Scandurra et al. / Disturbing or Facilitating?224
support future successful development of eHealth systems. Furthermore, the results
show that there seems to be a lack of knowledge in healthcare organizations concerning
how usability work should be conducted.
The relationship between poor usability and stress factors does not seem to be well
known in organizations, although healthcare professionals explicitly identify IT-related
disturbances as a major health and safety problem. Furthermore, continuous monitoring
of the usability of eHealth systems at the national level, which could serve as a basis
for collaboration and supervision in developing and adopting eHealth systems, is
currently missing. Specific evaluations have been made [1]. However, a long-term
follow-up on how usability evolves over time is still missing. Finally, there is a need to
deepen and disseminate the knowledge in the health and social care domains about
eHealth in general and about the usability aspect of eHealth systems in particular.
[1] Users Award, Vård IT-rapporten 2010 - en sammanfattning och Vård-IT-rapporten 2010 Enkätunder-
sökningar, flödesstudier och uppföljning av Vård-IT-kartan 2004: ,in Swedish. Retrieved 5 Jan 2014.
[2] Gartner, eHälsa i Sverige nuläge och framtida mål: Rapport för Socialdepartementet 2012:
[3] Viitanen J, Hyppönen H, Lääveri T, Vänskä J, Reponen J, Winblad I, National questionnaire study on
clinical ICT systems proofs: Physicians suffer from poor usability. Int J Med Inf, 80 (2011), 708-725
[4] International Organization for Standardization, ISO 9241-11:1998, Part 11: Guidance on usability _tc/catalogue_detail.htm?csnumber=16883
[5] Scandurra I, Störande eller stödjande? Om eHälsosystemens användbarhet 2013 Retrieved 5 Feb 2014
[6] Socialdepartementet, Nationell eHälsa - strategin för tillgänglig och säker information inom vård och
omsorg, S2010.020 (2010). Retrieved 5 Feb 2014.
[7] Riksrevisionen, .Rätt information vid rätt tillfälle inom vård och omsorg samverkan utan verkan? RiR
2011:19. Retrieved 2 feb 2014.
[8] Scandurra I, Åhlfeldt R, Persson A, Hägglund M., Building Usability into National eHealth Strategies,
an Action Research Approach. The 4th Infrastructure workshop on Infrastructures for Healthcare:
Action Research, Interventions, and Participatory Design. Tromsö, Norway, June 2013
[9] Bødker S, Ehn P, Sjögren D & Sundblad Y., Cooperative design perspectives on 20 years with "the
Scandinavian IT Design Model”. Proceedings of the first Nordic conference on Human-computer
interaction. Association for Computing Machinery, 2000.
[10] Stirna, J. Persson, A. Sandkuhl, K., Participative enterprise modelling: experiences and
recommendations, in Krogstie, J. Opdahl, A.L. Sindre, G. (Eds.): 19th Int Conf on Advanced
Information Systems Engineering (CAiSE 2007), LNCS 4495, 2007, Springer Verlag
[11] Scandurra I, Hägglund M, Koch S, From user needs to system specifications: multi-disciplinary
thematic seminars as a collaborative design method for development of health information systems
Journal of biomedical informatics 2008:41 (4): 557-569
[12] Rigby M, Hill P, Koch S, Keeling D. Social Care Informatics as an Essential Part of Holistic Health
Care: A Call for Action. Int J Med Inform (2011) 80: 544-554
[13] Söderström, E., Åhlfeldt, R-M and Eriksson, N. , Trusting digitized patient-related information: The
need for a new approach, In Furnell and Clarke (eds.), Proceedings of the 5th International Symposium
on Human Aspects of Information Security and Assurance (2011), London, pp.119-129, ISBN: 978-1-
[14] Åhlfeldt, R., Persson, A., Krasniqi, H., and Wåhlander, K. Supporting Active Patient and Healthcare
Collaboration - A Prototype for Future Healthcare Information Systems. In Sibte, Abidi and Bath (eds.),
Proceedings of the 16th International Symposium on Health Information Management Research
(ISHIMR 2013). Halifax, June 26-28 2013, pp 13-23, ISSN: 2048-4712
I. Scandurra et al. / Disturbing or Facilitating? 225
... Käytössä on muun muassa ammattilaisen ja asiakkaan välinen videoyhteys, reseptien uusinta sekä sähköinen ajanvaraus ja neuvonta [12][13][14][15]. Sähköisten palvelujen ei koeta kuitenkaan saavuttavan kaikkia tavoiteltuja hyötyjä muun muassa tietojärjestelmien riittämättömän käytettävyyden vuoksi [16][17][18][19][20]. Terveydenhuollon ammattilaiset kokivat, etteivät sähköiset palvelut tue heidän työprosessejaan [17,18,[21][22][23]. ...
... Kirjallisuuskatsaukseen perustuen palveluiden sähköistämisen ei koettu muuttavan työprosesseja, jonka vuoksi työskentely koettiin tehottomaksi. Sähköisten palvelujen käyttöönoton yhteydessä prosessien uudelleensuunnittelu ja kehittäminen koettiin tärkeäksi [2,19,20,23,28,29]. Tarpeena on, että järjestelmät integroituvat terveydenhuollon työprosesseihin ja muodostavat täten yhtenäisen kokonaisuuden [19]. ...
... Sähköisten palvelujen käyttöönoton yhteydessä prosessien uudelleensuunnittelu ja kehittäminen koettiin tärkeäksi [2,19,20,23,28,29]. Tarpeena on, että järjestelmät integroituvat terveydenhuollon työprosesseihin ja muodostavat täten yhtenäisen kokonaisuuden [19]. ...
Full-text available
Suomi tavoittelee digitalisaation edelläkävijyyttä uudistamalla julkisten palvelujen prosesseja ja sähköistämällä palveluja. Terveydenhuollossa sähköisten asiointipalvelujen käyttöönotolla tavoitellaan yhä parempia terveydenhuollon palveluita ja kustannushyötyjä. Sähköisten asiointipalveluiden käyttö on viime vuosina lisääntynyt, mutta käyttömäärä on edelleen alhainen digitalisaation toteutumiseksi. Sähköisten asiointipalveluiden käytön lisääntymisen yhdeksi haasteeksi on havainnoitu hoitoprosessien uudistamattomuus. Etelä-Pohjanmaan sähköisten asiointipalveluiden parantamiseksi, tämän tutkimuksen tavoitteena oli selvittää, miten terveydenhuollon hoitoprosessit huomioidaan sähköisten asiointipalveluiden kehittämistyössä Etelä-Pohjanmaalla. Tavoitteen saavuttamiseksi tutkittiin, millaisia sähköisiä asiointipalveluja terveydenhuollossa on käytössä ja kehitteillä, millaiseksi sähköisten asiointipalveluiden käytön yleisyys arvioidaan, millainen sähköisten asiointipalveluiden ja terveydenhuollon hoitoprosessien yhteenliittymä on, millä tavoin sähköisten asiointipalveluiden kehittämistyötä toteutetaan ja mitkä ovat Covid-19-pandemian vaikutukset sähköisiin asiointipalveluihin terveydenhuollossa. Tutkimuksen lähtökohta kuvattiin kirjallisuuskatsauksella, jossa haettiin tietoa terveydenhuollon sähköisistä palveluista Pohjoismaista. Tiedot terveydenhuollon hoitoprosessien huomioimisesta sähköisten asiointipalveluiden kehittämistyössä kerättiin terveydenhuollon ja tietohallinnon ammattilaisten haastatteluista. Terveydenhuollossa on käytössä erilaisia sähköisiä asiointipalveluja, joita on tarpeen kehittää sujuvamman asiointikokemuksen mahdollistamiseksi. Sähköisten asiointipalveluiden käyttöönottojen yhteydessä tehdään muutoksia hoitoprosesseihin, mutta prosesseja ei uudisteta suunnittelemalla, miten sähköisten palvelujen hyödyt saavutetaan. Sähköisten asiointipalveluiden kehittämistyötä toivottiin edistettävän ja sisällyttämään työhön prosessisuunnittelu entistä vahvemmin. Sähköisten palveluiden ja prosessien muotoilulle yhtenäiseksi kokonaisuudeksi on olemassa hyvät edellytykset. Tulevaisuudessa on tärkeää määritellä sähköisten asiointipalveluiden hyötytavoitteet ja tehdä strategia niiden saavuttamiseksi. Sähköisten asiointipalveluiden hyödyt konkretisoituvat, kun määritellyt prosessivaiheet digitalisoidaan siten, että ne ovat osa työkäytänteitä ja kansalaisten asiointia.
... In further research, the usability of the D-Foot should be evaluated by all users: patients, CPOs, healthcare managers, IT experts and other healthcare givers (27). Moreover, a long-term effect of using a CDSS, with a reduction in the number of DFUs in primary care, is expected and should be of interest in future studies. ...
... Many participants answered these questions with "not applicable!". Even if the NPS, the nationwide survey used to measure patient-perceived quality and experience of healthcare, was recommended (31), we suggest that OPUS with the Client Satisfaction with Services module (CSS) should be used in further studies as a tool to assess how satis ed patients are with the devices and the services at the DPO (37,38), in addition to qualitative methods for studying usability (27). ...
Full-text available
Background: Digital solutions in healthcare can facilitate and improve care. However, the experiences and usefulness of using either digital foot examinations or traditional foot examinations need to be evaluated. The aims of the study were to evaluate: 1) the differences in patient experiences, having their foot examined supported by the Clinical Decision Support System (CDSS) as compared with having their foot examined in traditional practice, 2) how healthcare professionals (HCP), by using the CDSS, experienced the routine compared with performing the foot examination as in traditional practice. Methods Of a total of 141 patients, 100 patients with diabetes were single-blind digitally randomised to one of two parallel arms: having their foot examined by an HCP using a CDSS (n=47) or having their foot examined as in traditional practice (n=53) at the Department of Prosthetics and Orthotics at Sahlgrenska University Hospital, Gothenburg, Sweden. Patients filled in a modified version of the National Patient Survey (NPS) and the Orthotics and Prosthetics Users’ Survey (OPUS) at study end. Two HCPs, working at a Department of Prosthetics and Orthotics, answered surveys regarding the interaction between the patient and the CPO. Results: Patients, aged 65±14 years, perceived a high level of satisfaction with the service at the department, regardless of the method used. No significant differences between groups were found when evaluated by 27 questions in the NPS or the OPUS, with scores of 67.17±12.18 vs. 66.35±16.52 (p=0.78) for the intervention and control group respectively. One hundred per cent of the patients were risk classified in the intervention group compared with 2% in the control group. Conclusions: Patients perceived a high level of satisfaction with the services at the DPO, regardless of the method used for the foot examination. All the patients were risk classified in the intervention group. The HCPs found that, by using the CDSS, the foot examination was structured and followed clinical guidelines. Furthermore, the documentation in the electronic health record was thorough, even though further improvements, such as integration with co-existing health record systems, were requested. Trial registration: Clinical Trials NCT03088566, Registered 23 March 2017,
... It has been suggested that digital tools, such as the D-Foot, improve DFU management in care [28][29][30][31] and stored data can be useful when auditing the care of DFU patients to support clinical improvements, as presented by Leese et al. [30]. Continuous improvements based on the users' experiences to develop and implement improvements are necessary [32,33]. ...
... A variety of comments were collected from the CPOs and these comments from users are useful in the continuous improvement of digital tools such as the D-Foot software [32]. In future versions, the authors suggest that improvements should be made. ...
Full-text available
Background Individuals living with diabetes run an increased risk of developing diabetic foot ulcers (DFUs), leading to high costs to society and reduced quality of life for the individual. Regular screening is important to avoid complications. Aim To evaluate patients’ and clinicians’ experiences of using a digital tool, the D-Foot, in the screening of risk factors for developing DFUs. The secondary aims were to investigate whether patients had had their feet examined by a nurse or doctor during the past year, had been referred to podiatry and whether patients had received information about self-care. Methods A prospective study was carried out, comprising 90 patients with diabetes visiting a Department of Prosthetics and Orthotics (DPO). Two Certified Prosthetists and Orthotists (CPOs) were included, and they assessed foot status and the risk of developing DFUs with the D-Foot software, prior to prescribing footwear. The quality of services at the DPO was assessed by the patients using the Orthotics and Prosthetics Users’ Survey (OPUS). The CPOs answered the System Usability Scale (SUS) before and after the study to assess the usability of the D-Foot. Results No patient had risk grade 1. One (1%) patient had risk grade 2, 78 (87%) patients had risk grade 3 and 11 (12%) patients had risk grade 4. Patients reported high levels of satisfaction on eight of ten OPUS items and the two items with lower scores were not related to the use of the D-Foot. The two CPOs reported levels above the mean regarding usability both before (77.5 and 90) and after (70 and 97.5) using the D-Foot. Conclusions Patients expressed a high level of satisfaction with the services when their feet were examined with the D-Foot prior to the provision of footwear. The CPOs found that the D-Foot system was usable. Several comments were made by patients and CPOs and will support the future development and testing of the D-Foot. There is a need to increase referrals for preventive podiatry and improve information on self-care for patients at risk of DFUs. Trial registration ID: NCT04054804.
... By enabling clinicians to make better use of information, HIT has the potential to support them in taking the right decisions and actions, thereby improving patient outcomes. However, HIT is often plagued by usability issues [1,2], which has been associated with negative outcomes for both patients and healthcare professionals [3]. Nurses, as the largest group of HIT users [4], have been particularly affected by the issues emerging from its use. ...
... Usability is hence an assessment of 1) whether users can perform their work tasks with the system (e.g., marking a drug prescription as administered), 2) how quickly these work tasks can be carried out in the system (e.g., how long it takes to mark a drug prescription as administered), and 3) users' subjective assessment of how well a system fulfils their use needs. The lacking usability of HIT has been widely acknowledged in the literature [1][2][3], including in the specific context of hospital nursing. In their recent examination of nurses' usability problems with HIT, Staggers et al. [6] found a wide range of issues, including mismatches between nurses' work practice and system design (e.g., single patient views while nurses care for groups of patients, individual work view while nurses work as part of an interdisciplinary team), fragmentation of patient information within and across systems, and lack of internal and external system interoperability. ...
Conference Paper
Full-text available
Often, Health Information Technology (HIT) in hospitals consists of off the shelf systems that are configured and implemented by IT department workers. This means that these employees have a significant impact of the usability of HIT systems. Nonetheless, we currently do not know how IT department workers work. This prevents us from formulating educated recommendations aimed at improving HIT usability, known to be poor, especially from nurses’ perspective. In this paper, we hence present the results from an interview study, shedding light on 1) the communication channels that exist between nurses and IT department at a large public hospital in Sweden, and 2) the problems that undermine system-related communication between these two groups. Our findings stress the need for successful two-way communication between nurses and IT department in order to improve the usability of HIT in use.
... In our study, the participants described different types of support; collegial support through online forums, and technical support that was fast and efficient (often contrasted with dysfunctional support in physical care). Poor usability of eHealth systems is a well-known problem, in Sweden [29] and internationally [30][31][32]. Our participants' frustration with the eHealth systems and technical support in physical care, was described as part of the reasons for working for an online healthcare provider. ...
Full-text available
Background The use of remote services such as video consultations (VCs) has increased significantly in the wake of the COVID-19 pandemic. In Sweden, private healthcare providers offering VCs have grown substantially since 2016 and have been controversial. Few studies have focused on physicians’ experiences providing care in this context. Our aim was to study physicians’ experiences of VCs, focusing on the work environment, quality of care, and educational needs. Methods Twenty-two semi-structured interviews were performed with physicians working with VCs in Sweden, and analyzed through inductive content analysis. Results We identified five categories; flexibility, social work environment, impact on care and society, continuous learning and career development, and organizational support. Flexibility and accessibility were considered positive features of working digitally by giving physicians control over their time and workplace and increasing patients’ timely access to healthcare. Regarding collegial contact and social activities in a digital context, the majority of the participants did not experience any significant difference compared to the physical context. Access to technical support services, educational support, and collegial support in decision-making, guidance, and consultations were described as well-functioning. Satisfied patients positively impacted the work environment, and participants felt that VCs have a positive socio-economic effect. Continuity of care was considered supported, but patients did not always prioritize this. Privacy risks were considered a challenge, as were poor development of clinical skills due to the low variation of patient cases. Working for an online healthcare provider was contributing to career advancements for junior clinicians. Conclusions Physicians appreciate the flexibility of the digital context and seem satisfied with a work environment where they have a high level of control, but few consider this a full-time career option. The pandemic year 2020 has led to a significant increase in the implementation of VCs in traditional care systems. How this affects the work environment and continuous education needs and career development remains to be seen.
... Some of the problems mentioned related to the quality of working life in the literature are high workload, control, responsibility, workload and unsatisfactory working conditions. 2 Another factor in nurses' decreased quality of working life is the increasing reliance on information and communication technology solutions in nurses' work. [3][4][5][6] There is an increased digitalisation and, for example, the number of patient services launched, which further affects nurses' work environment. However, despite several benefits, digitalisation often has unexpected negative consequences in healthcare. ...
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Objectives The introduction of information and communication technology influences the work environment of large groups of employees in healthcare. In Sweden, a national healthcare service providing patient accessible electronic health records (PAEHR) has been deployed, and this paper investigates nurses’ expected effects of this implementation. Setting Nurses associated with the Swedish Association of Health Professionals working in healthcare such as primary care, hospitals and midwives in Sweden. Before a full-scale national implementation of PAEHR, a web survey study was distributed nationally. The respondents represented all 21 Swedish regions. Questions included five-point Likert scale questions and open questions. Participants A survey link was distributed via email to 8460 registered nurses, midwives and union representatives in Sweden. The response rate was 35.4% (2867 respondents: registered nurses 84%; midwives 6%; chief position 5%; in projects 2% and other 3%). Three reminders were sent out, all of them increasing the response rate. A majority of the respondents were female (89.9%), 8.4% male, whereas 1.7% did not indicate their gender. 31.4% were under 40 years old, 53.8% 40–59 and 13.7% over 60. Results Data were analysed using exploratory factor analysis with principal component analysis as the extraction method. The analysis revealed three distinct factors related to nurses’ expectations of PAEHR: (1) PAEHR improves the quality of care, (2) PAEHR improves the quality of the work environment and (3) risk and fears concerning patients’ well-being. Some interesting results include that more experienced nurses are more favourable to PAEHR. Our analysis also shows that the view of the nurse–patient relationship is an essential underlying factor related to positive or negative expectations. Conclusions Results show that the expectations and perceptions of PAEHR vary depending on the nurse’s view of who the electronic record belongs to. Younger nurses are somewhat more negative towards PAEHR than older nurses.
... However, recent reports by Golay suggests unexpected work and invisible new tasks are being introduced as a result of new technology [4]. Given the work environment problems in healthcare, with a large turnover of especially nurses [5] and recent evidence that suggest digitalisation is experienced as a part of the problem by many healthcare professionals [6,7], it is vital to investigate the effects of automation and digitalisation on work engagement. ...
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Digitalising patient-centric services to address society’s challenges with an ageing population and healthcare provision is by many seen as important. Studying the effects of the digitalisation on the work engagement of the users of the new systems is vital in this context, especially since previous research has established that the work engagement at work in healthcare is problematic. Work engagement is defined as a positive, fulfilling, affective-motivational state of work related well being, as is closely connected to the experience of resources and demands in the work context. These resources can be for example digital support, experienced demands or empowerment whereas exhaustion is connected to work demand in a workplace. This study contributes to knowledge about the effects of digitalisation on work engagement and exhaustion in the context of patient-centred services and eHealth. Contextual interviews were conducted on site for 5 h with nurses using a new chat function and using telephone for medical advice to patients. Additionally, semi-structured interviews were conducted with all the nurses participating in this digitalisation project to gather more insights into their work engagement in the two work situations. Results were analysed in different themes of areas affected by the digitalisation in the two overarching themes: job demands and job resources. The results show that the change to a chat function when communicating with advice seekers had connection to work engagement in several ways. The nurses experienced less time pressure and emotional pressure, but also a loss of job control and feedback from colleagues working from home.
... Globally, healthcare systems are facing similar challenges and a pressure to perform alongside limited budgets and shortage of staff. eHealth has the potential to facilitate the work for healthcare professionals, however problems with low usability and poor interoperability continue to cause problems [1]. Low-and middle-income countries (LMICs) suffer from several health care challenges, one of the major ones being lack of workforce. ...
Community Health Workers (CHW) perform important healthcare and health promotion in many low and middle income countries. They are increasingly supported in their work by the use of mHealth. This study aims to explore how mHealth services can support the everyday work for CHWs when delivering home care in rural areas in South Africa. A single case study was performed, mapping CHWs workflow and investigating where and when CHW can be supported by mHealth services. Despite the very positive feedback from the CHWs and the fact that the studied mHealth solutions appears to support the majority of the important activities in the CHWs work process, the application is no longer in use. Financial and strategic decisions are behind the discontinuation of the project, further stressing the importance of taking all socio-technical dimensions into account when evaluating success or failure of implementation projects.
... Lombardy region in Italy [20] and openEHR implementation in Chinese hospitals [21,22]. Yet, interoperability of HIS remains a problem in most healthcare systems and was identified as still being a major issue for usability of eHealth in Sweden in a study from 2013 [23]. ...
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Background Patients and citizens need access to their health information to get a retrospective as well as a prospective view on their care and rehabilitation processes. However, patients’ health information is stored in several health information systems and interoperability problems often hamper accessibility. In Sweden a national health information exchange (HIE) platform has been developed that enables information exchange between different health information systems. The aim of this study is to explore the opportunities and limitations of accessing and interacting with important health information through the Swedish national HIE platform. Methods A single case study approach was used for this study as an in-depth understanding of the subject was needed. A fictive patient case with a pseudo-name was created based on an interview with a stroke coordinator in Stockholm County. Information access through the national health information exchange platform and available service contracts and application programming interfaces were studied using different scenarios. Results Based on the scenarios created in this study, patients would be able to access some health related information from their electronic health records using the national health information exchange platform. However, there is necessary information which is not retrievable as it is either stored in electronic health records and eHealth services which are not connected to the national health information exchange platform or there is no service contract developed for these types of information. In addition, patients are not able to share information with healthcare professionals. Conclusion The national Swedish HIE platform provides the building blocks needed to allow patients online access to their health information in a fragmented and distributed health system. However, more complex interaction scenarios allowing patients to communicate with their health care providers or to update their health related information are not yet supported. Therefore it is of great importance to involve patients throughout the design and evaluation of eHealth services on both national and local levels to ensure that their needs for interoperability and information exchange are met. Electronic supplementary material The online version of this article (10.1186/s12911-019-0816-x) contains supplementary material, which is available to authorized users.
Background: Health-related applications are concerned with human life. These applications should be developed and evaluated to minimize any potential risk while applied. One of the most common usability evaluation methods is known as heuristic evaluation. Thus, the present study aimed to propose an initial model for the heuristic evaluation of health-related applications. Methods: To propose this model, the existing methodologies were modified. In the present study, the three primary stages of the methodology were reported. In the first and second stages, having identified the relevant keywords, a search was done in the databases. After the initial screening and extraction of heuristics and important criteria in the first two stages, the research findings and data abstraction were done qualitatively in the third stage. Results: A total number of twenty-one heuristics in the proposed model were mapped into two categories, traditional and non-traditional. Ten heuristics were placed in the former and eleven in the latter. Flexibility and efficiency of use, Aesthetic and minimalist design heuristics in the first category and User engagement and Privacy and security heuristics in the second category had the largest number of items. Technical features and support heuristic were also added to the second stage. Conclusion: This initial model can be used by healthcare providers, engineers, developers, researchers and health policymakers. Using a pre-defined model or framework to evaluate health-related applications saves time and money.
Conference Paper
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Many healthcare organizations are currently committed to organizational change and quality improvement projects. Unfortunately, little effort is put into health information system development according to usability requirements and methodology, leading to bottlenecks in the eHealth systems when implemented into daily practice. This paper presents a national initiative to build usability of eHealth systems into the Swedish national eHealth strategy and its action plan to ensure impact on practice. Action researchers within the health informatics domain collaborated with representatives of different care professions to propose high-priority changes necessary to improve the usability of health information systems.
Conference Paper
Trust is receiving increasing attention nowadays, particularly since new technology enables communication and collaboration like it has never been seen before. However, trust is a fuzzy concept that needs further examination and attention from multiple levels. For example, security is very important from a user’s point of view in trusting that technology will function in accordance with the user’s intended and requested function. This paper reviews the concept of patient safety, which thus far has been discussed and defined from a narrow technical perspective. We demonstrate that it is much more complex, and that it is not primarily the technical issues that are problematic, but rather the cultural, process-related and personnel issues. Our results point to a need for a new approach, which takes the patients’ view of healthcare and the patient-related digital information as its focus. The discussion is made from a Swedish perspective, but the issues are international. The needs for information and knowledge in healthcare are obvious. Without clear definitions of concepts and roles, a good information flow or process cannot be designed. Our discussion shows that trusted digital patient information gives an opportunity for a patient-focused healthcare. Multidimensional trust must be addressed on all levels; organization, person and technology. More empirical research into trust in digital patient-related information is necessary, to develop a model for patient safety from a trust perspective that encompasses all levels of trust.
Conference Paper
The objective of this paper is to report a set of experiences of applying participative enterprise modeling in different organizational contexts. While the authors have successfully applied the approach in many organizations, the paper primarily concentrates on three cases. On the basis of these experiences the paper presents a set of generic principles for applying participative enterprise modeling.
Objective: In the health informatics field, usability studies typically focus on evaluating a single information system and involve a rather small group of end-users. However, little is known about the usability of clinical information and communication technology (ICT) environment in which healthcare professionals work daily. This paper aims at contributing to usability research and user-oriented development of healthcare technologies with three objectives: inform researchers and practitioners about the current state of usability of clinical ICT systems, increase the understanding of usability aspects specific for clinical context, and encourage a more holistic approach on studying usability issues in health informatics field. Methods: A national web questionnaire study was conducted in Finland in spring 2010 with 3929 physicians actively working in patient care. For the purposes of the study, we described three dimensions of clinical ICT system usability that reflect the physicians' viewpoint on system usage: (1) compatibility between clinical ICT systems and physicians' tasks, (2) ICT support for information exchange, communication and collaboration in clinical work, and (3) interoperability and reliability. The dimensions derive from the definitions of usability and clinical context of use analysis, and reflect the ability of ICT systems to have a positive impact on patient care by supporting physicians in achieving their goals with a pleasant user experience. The research data incorporated 32 statements with a five-point Likert-scale on physicians' experiences on usability of their currently used ICT systems and a summative question about school grade given to electronic health record (EHR) systems. Results: Physicians' estimates of their EHR systems were very critical. With the rating scale from 4 or fail to 10 or excellent, the average of the grades varied from 6.1 to 8.4 dependent on the kind of facility the physician is working. Questionnaire results indicated several usability problems and deficiencies which considerably hindered the efficiency of clinical ICT use and physician's routine work. Systems lacked the appropriate features to support typical clinical tasks, such as decision making, prevention of medical errors, and review of a patient's treatment chart. The systems also required physicians to perform fixed sequences of steps and tasks, and poorly supported the documentation and retrieval of patient data. The findings on ICT support for collaboration showed mainly negative results, aside from collaboration between co-located physicians. In addition, the study results pointed out physicians suffering from system failures and a lack of integration between the systems. Conclusions: The described study and related results are unique in several ways. A national usability study with nearly 4000 respondents had not been conducted in other countries in which healthcare technologies are widely adopted. The questionnaire study provided a generalized picture about the usability problems, however, it should be noted that there were significant differences between legacy systems in use. Previously, researchers had not approached contextual aspects of usability the context of clinical work, where numerous systems are in use. The described usability dimensions and the presented study results can be considered as the first step towards conceptualizing ICT usability in the unique setting of clinical work.
This paper presents a new multi-disciplinary method for user needs analysis and requirements specification in the context of health information systems based on established theories from the fields of participatory design and computer supported cooperative work (CSCW). Whereas conventional methods imply a separate, sequential needs analysis for each profession, the "multi-disciplinary thematic seminar" (MdTS) method uses a collaborative design process. Application of the method in elderly homecare resulted in prototypes that were well adapted to the intended user groups. Vital information in the points of intersection between different care professions was elicited and a holistic view of the entire care process was obtained. Health informatics-usability specialists and clinical domain experts are necessary to apply the method. Although user needs acquisition can be time-consuming, MdTS was perceived to efficiently identify in-context user needs, and transformed these directly into requirements specifications. Consequently the method was perceived to expedite the entire ICT implementation process.
eHälsa i Sverige – nuläge och framtida mål: Rapport för
  • Gartner
Gartner, eHälsa i Sverige – nuläge och framtida mål: Rapport för Socialdepartementet 2012: 330006695
Part 11: Guidance on usability http
International Organization for Standardization, ISO 9241-11:1998, Part 11: Guidance on usability _tc/catalogue_detail.htm?csnumber=16883