Disturbing or Facilitating?
– On the Usability of Swedish eHealth
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 . 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: firstname.lastname@example.org
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].
The Swedish National Strategy for eHealth in Health and Social Care  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” . The Gartner report ,
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 , which was the starting point for the
study presented in this paper; Usability of Swedish eHealth Systems 2013 (USeHS).
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 . 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 .
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 . 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 . 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,
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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.
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 . 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
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
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.
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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 sectors’ as 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 . In the health
and social care of municipalities, access to mobile and situation–based eHealth systems
and tools must improve substantially .
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
. 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 .
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 . 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.
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