title: Navigation in the electronic health record: A review of the safety and usability literature.
abstract: Inefficient navigation in electronic health records has been shown to increase users' cognitive load, which may increase potential for errors, reduce efficiency, and increase fatigue. However, navigation has received insufficient recognition and attention in the electronic health record (EHR) literature as an independent construct and contributor to overall usability. Our aims in this literature review were to (1) assess the prevalence of navigation-related topics within the EHR usability and safety research literature, (2) categorize types of navigation actions within the EHR, (3) capture relationships between these navigation actions and usability principles, and (4) collect terms and concepts related to EHR navigation. Our goal was to improve access to navigation-related research in usability.
  
  
  
  We applied scoping literature review search methods with the assistance of a reference librarian to identify articles published since 1996 that reported evaluation of the usability or safety of an EHR user interface via user test, analytic methods, or inspection methods. The 4336 references collected from MEDLINE, EMBASE, Engineering Village, and expert referrals were de-duplicated and screened for relevance, and navigation-related concepts were abstracted from the 21 articles eligible for review using a standard abstraction form.
  
  
  
  Of the 21 eligible articles, 20 (95%) mentioned navigation in results and discussion of usability evaluations. Navigation between pages of the EHR was the more frequently documented type of navigation (86%) compared to navigation within a single page (14%). Navigation actions (e.g., scrolling through a medication list) were frequently linked to specific usability heuristic violations, among which flexibility and efficiency of use, recognition rather than recall, and error prevention were most common.
  
  
  
  Discussion of navigation was prevalent in results across all types of evaluation methods among the articles reviewed. Navigating between multiple screens was frequently identified as a usability barrier. The lack of standard terminology created some challenges to identifying and comparing articles.
  
  
  
  We observed that usability researchers are frequently capturing navigation-related issues even in articles that did not explicitly state navigation as a focus. Capturing and synthesizing the literature on navigation is challenging because of the lack of uniform vocabulary. Navigation is a potential target for normative recommendations for improved interaction design for safer systems. Future research in this domain, including development of normative recommendations for usability design and evaluation, will be facilitated by development of a standard terminology for describing EHR navigation.
authors.affiliation: Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY, United States. Electronic address: lir2029@alumni.weill.cornell.edu.
authors.forename: Lisette C
authors.initials: LC
authors.lastname: Roman
authors.affiliation: Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY, United States. Electronic address: jsa7002@med.cornell.edu.
authors.forename: Jessica S
authors.initials: JS
authors.lastname: Ancker
authors.affiliation: Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY, United States. Electronic address: johnsos@med.cornell.edu.
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Johnson
authors.affiliation: Department of Medical Informatics, SUNY Downstate Medical Center, Brooklyn, NY, United States. Electronic address: yalini.senathirajah@downstate.edu.
authors.forename: Yalini
authors.initials: Y
authors.lastname: Senathirajah
mesh_terms: D003071:Cognition; D057286:Electronic Health Records; D006801:Humans; D011642:Publications; D014584:User-Computer Interface
keywords: Electronic health record; Navigation; Safety; Scoping review; Usability