International Journal of Industrial Ergonomics 41 (2011) 345e351

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International Journal of Industrial Ergonomics

journal homepage: www.elsevier.com/locate/ergon

Ergonomics concerns and the impact of healthcare information technology

Alan Hedge a, *, Tamara James b, Sonja Pavlovic-Veselinovic c
a
Department of Design and Environmental Analysis, Cornell University, Ithaca, NY 14853, USA
b
Ergonomics Division, Occupational and Environmental Safety, Duke University, Durham, NC 27710, USA
c
Faculty of Occupational Safety, University of Nis, Nis, Serbia

a r t i c l e i n f o a b s t r a c t

Article history: The US healthcare industry is poised on the verge of a massive expansion of its information technology
Received 31 August 2009 infrastructure. Healthcare information technology (IT) is permeating numerous areas of healthcare
Received in revised form delivery and fundamentally changing the nature of many healthcare jobs. When a comparable expansion
11 June 2010
in HIT use occurred in the office environment in the 1980s, little attention was paid to ergonomic design
Accepted 10 February 2011
Available online 23 March 2011
principles for computer work and the consequence was an increase in work-related musculoskeletal
disorders throughout the 1990s. There are already signs of similar problems among certain groups of
healthcare professionals. Consequently, it is vital that when the implementation of HIT is undertaken
Keywords:
Healthcare information technology
attention is paid to computer ergonomics programs. This review presents evidence that current patterns
Computer ergonomics of HIT use may pose increased risks of work-related musculoskeletal disorders. It summarizes some of
Musculoskeletal injuries the main ergonomic design principles enshrined in standards that mitigate such problems. It points to
Hospital ergonomic design the future expansion of ergonomics programs beyond the traditional workplace and into the realms of
Computers on wheels telecommuting. Results from this review can be used to optimize the implementation of future HIT
Ergonomics programs initiatives in ways that will benefit user performance while minimizing their injury risks.
Telework Relevance to industry: This review describes the rapid proliferation of HIT applications and the impor-
Telecommuting
tance of ergonomic considerations in mitigating injury risks and optimizing the implementation of HIT
systems.
Ó 2011 Elsevier B.V. All rights reserved.

1. Introduction
Healthcare is a substantial and growing sector of the US
economy comprising over 95,800 establishments that provide
some 14.3 million jobs and account for 1 in 11 US workers (Bureau
of Labor Statistics, 2010). Around one in three healthcare workers
work in a hospital even though hospitals are only about 1.3% of all
healthcare establishments. Three-quarters of healthcare establish-
ments are the offices of physicians, dentists or other healthcare
professionals.
Current demand for healthcare services is partly being driven by
the aging of the US workforce. Almost 80 million baby boomers
approaching retirement age are expected to place an increasing
demand on these services in the next two decades and the antici-
pated increase in demand for healthcare services is projected to
generate some 3.2 million new jobs by 2018, and the healthcare
sector is projected to grow from around $2.4 trillion or 17% of GDP
* Corresponding author.
E-mail address: ah29@cornell.edu (A. Hedge).
in 2007, to around $4.3 trillion, or some 20% of GDP, by 2017. Along
with this anticipated growth in demand, advances in medical
science are dramatically improving medical diagnostics and ther-
apeutic interventions which are prolonging the average life. At the
same time, healthcare costs are rising at double the inflation rate, or
some 6.9% in 2008, and consequently in the US there is consider-
able interest in ways to reduce healthcare costs while, at the same
time, increasing access to healthcare services that can meet the
projected demand. In February 2009, the US Congress passed the
American Recovery and Reinvestment Act which budgets $20
billion for investment into healthcare information technology (HIT)
infrastructure and systems as a means to save on costs, reduce the
incidence of medical errors and improve patient safety and the
quality of healthcare.
Yet ironically, the workers in the healthcare profession are at
higher risk of suffering an occupational musculoskeletal disorder
(MSD) than most other workers. Nursing aides, orderlies and
attendants have an MSD rate of 252 cases per 10,000 workers,
which is some 7 times the national average for all occupations
(Bureau of Labor Statistics, 2010).

0169-8141/$ e see front matter Ó 2011 Elsevier B.V. All rights reserved.
doi:10.1016/j.ergon.2011.02.002
346 A. Hedge et al. / International Journal of Industrial Ergonomics 41 (2011) 345e351
Research has shown that the prevalence of self-reported MSDs
among healthcare professionals can be high both for nurses and
physicians and these risks will be impacted by the use of HIT.
A survey of 162 Korean female nurses working in various hospital
settings found that 56.8% reported an MSD symptom with
a duration of at least 1 week or occurring at least once a month
for the previous 12 months (Kee and Seo, 2006). A study of 5269
Taiwanese nurses reported that 91.6% experienced MSDs and pain
in different body parts was related to different ergonomic risk
factors, especially bending, twisting of the waist and standing for
extended periods of time (Hou and Shiao, 2006). The prevalence
of MSDs is related to the perceived physical demands of tasks
which are influenced by work postures, and tasks involving
awkward positions are most strongly associated with reported
MSDs at all body sites. A survey of 1163 registered nurses in the
United States (94% were female, 46% were hospital nurses and
54% were staff nurses) found that tasks requiring moderate
physical demands raised the odds ratio (OR) for an MSD to
between 1.4 and 3.6, and those requiring a high physical demand
raised the OR for an MSD to between 4.4 and 12.0 (Trinkoff et al.,
2003). Research on 113 healthcare workers in 15 hospital wards in
Italy found that 71% reported at least 1 MSD, and the MSD
prevalence was highly associated with work-related awkward
postures (71%) and greater than that observed among hospital
workers exposed to manual lifting (21%) (Gerbaudo and Violante,
2008). A survey of 361 Chinese doctors found that the 12 months
MSD period-prevalence for any region of the body was 67.5% and
the prevalence by body region was lower back (43.7%); neck
(42.3%); shoulder (37.8%); and upper back (29.0%), and women
were more susceptible to an MSD than men (OR: 3.05) (Smith
et al., 2006).
The increased use of HIT is changing the task requirements of
nurses and physicians. Nurses can spend up to 3 h per shift seated
at a computer workstation and up to 4.8 h per shift at a standing
computer workstation, and all too often the nursing computer
workstations have improper counter heights for the height of the
staff, old equipment that is poorly laid out, inadequate workspace
and improper lighting (Nielsen and Trinkoff, 2003). As a conse-
quence of the poor ergonomic design of nursing computer work-
stations this research found that 32% of nurses using a computer
reported an upper extremity musculoskeletal disorder (UEMSD)
and 60% of these UEMSDs were carpal tunnel syndrome cases, and
poor workstation design requiring frequent awkward postures was
identified as the major risk factor.
MSD problems are already widespread among healthcare
workers, and the projected increased use of HIT without atten-
tion to ergonomic considerations may increase MSD prevalence,
especially for upper extremity MSDs (UEMSDs). A before-and-
after evaluation of the use of a computerized provider order-
entry (CPOE) system, which is used to communicate orders from
medical staff to other departments such as radiology, pharmacy,
or laboratories, found that this direct patient care decreased for
physicians (36.8%e29.1%) and also slightly for nurses (56.9%e
55.3%) with more time being spent at the computer (Asaro and
Boxerman, 2008). Another recent CPOE evaluation study found
that while this did not affect the percentage of time spent in
direct patient interactions by attending and resident physicians
and resident nurses, it did increase physician time spent using
a computer for patient care and decreased time spent walking for
all groups (Yen et al., 2009). The physical attributes of a computer
has been found to shape patienteprovider encounters, especially
computer size and the flexibility of computer position, which was
a leading influencing factor in how a physician engaged patients
with thinner, more flexible monitors with articulating arms
facilitating communication and collaboration between provider
and patient (Ventres et al., 2006). Research has yet to be con-
ducted on the role that increased HIT use might play concerning
UEMSDs among nurses and physicians, but the trend to increased
computer use and more sedentary work patterns emphasizes the
importance of good ergonomic workstation design.
2. Opportunities for the ergonomic design of HIT
workstations
HIT is being used in a wide variety of healthcare situations, and
the following are some examples of this in a hospital setting.
2.1. In-room computer wall station
In modern hospitals there is a trend to place a computer in every
patient room to provide physicians and nurses with point of care
access to the hospital electronic medical record (EMR) system to
retrieve, allow entry of patient information and medication status,
electronically monitor the patient, and facilitate patient discussions
with physicians and nurses on their health status. However, espe-
cially in older facilities where patient rooms were not designed to
easily support HIT infrastructure there can be issues of space, fire
safety codes, flexibility of positioning input devices and screen,
provision of power and cabling, and providing suitable range of
adjustability for various users. Vertical track mounted wall stations
can provide HIT support surfaces in some patient rooms and these
can be both height and reach adjustable to accommodate up to 99%
of users in either seated or standing positions. Many wall station
designs provide flexibility in monitor positioning which enables
caregivers to maintain visual contact with patients at all times.
Research on the horizontal arrangement of computer screens has
shown that the lowest neck muscle activity and greatest comfort
occur when the screen is centrally positioned in front of the person,
with the screen being positioned at 35
to the right being the next
best position, and the screen being placed 35
to the left of the
person being the worst position (Szeto and Sham, 2008). Using an
LCD monitor arm allows maximum flexibility of the computer
screen and this has been shown to have beneficial effects on some
MSD symptoms and comfort (Boothroyd and Hedge, 2007). The
optimal vertical position of a computer screen varies depending on
the user, his/her posture, and whether or not there is touch inter-
face with the screen. The ideal range of screen height from a 5th
percentile woman to a 95th percentile man for standing use is
4800 e6000 and for sitting use it is 4000 e5300 (HFES, 2007).
Vertical track mounted wall stations also can provide an
adjustable keyboard/mouse platform that can fold flat for efficient
storage; they can allow easy, fast, intuitive, fingertip adjustability
for frequent position changes to accommodate different users and
tasks; they can integrate power management and communications
cabling; they can eliminate sharp edges that could create contact
stress or a contusion; and they can present antimicrobial and easy
to clean surfaces for optimal hygiene. Issues of hygiene are
important because in-room computers are used by multiple people
and regular computer keyboards and mice in healthcare settings
can readily harbor pathogenic microorganisms, such as Staphylo-
coccus aureius (Palenik and Hughes, 2008), methicillin resistant S.
aureius (MRSA) (Wilson et al., 2008), and Clostridium difficile
(Dumford et al., 2009). On average, an in-room keyboard and
mouse are touched over 34 times per hour in a healthcare setting
and membrane keyboard covers quickly become contaminated
within a day (Wilson et al., 2006). The risk of transmission of MRSA
and other bacteria between keyboards and distant patients likely
will increase significantly with the introduction of electronic
patient records and implementing appropriate infection control
 A. Hedge et al. / International Journal of Industrial Ergonomics 41 (2011) 345e351
cleaning measures and purchasing equipment with antimicrobial
properties can help maintain hygienic conditions.
2.2. Computers on wheels (COWs)
In many hospitals computers on wheels (COWs) are used which
are push carts that can be moved from room to room to provide
mobile computer access. COW use allows a single computer to be
used in many places in the hospital, and this is a space saving
solution. COWs can provide adjustability for the input device
surface and the monitor screen, and incorporate a mobile power
unit that allows for laptop use throughout an 8 h shift. Some
ergonomic design issues that have been identified include the fact
that, for durability, COWs often are metal, which makes them heavy
and present users with cold surfaces and sharp edges; wheel design
is often inadequate for varying surfaces and easy steering, with
some designs providing only rear wheels that can change direction,
making the cart very hard to maneuver; limited on-cart storage
and/or area for paperwork; the lack of a battery power indicator;
the stability of the input device platform; and the size of the cart
making it difficult to navigate in and out of patient rooms and to
store between shifts (Whittemore and Moll, 2008).
Most nursing computer tasks are conducted in patient rooms
(56.7%) or in the corridors (35.8%), with only a small percentage at
a patient’s bedside (5%). Physicians on ward rounds perform 56% of
computer tasks in the corridors, 29% in patients’ rooms, and 3% at
the bedside, and 57.3% of clinical tasks at generic COWs and 35.9%
on tablet computers. Physicians not on ward rounds perform 93.6%
of tasks using stationary computers, most often within their offices
(Andersen et al., 2009). The effects of keyboard cleaning on mobile
carts have been investigated in a 16 bed intensive care unit (ICU)
and organizational factors have been shown to play a major role
because daily cleaning did not occur even though some of the
COWs were moved in and out of isolation rooms known to be
contaminated with either MRSA or vancomycin-resistant Entero-
coccus. Corralling the COWs and assignment of keyboard cleaning
to a member of the housekeeping staff was necessary to achieve
100% keyboard cleaning for infection control (Po et al., 2009).
2.3. Radiology reading rooms
Although often overlooked, creating an effective reading room
environment is critical to the productivity, health and well-being
of the radiologist, and the successful implementation of PACS
(Picture Archiving and Communication Systems) in a facility. Even
though it has been noted that a majority of today’s digital reading
rooms may be poorly designed for the required tasks (Horii et al.,
2003), little research on environmental factors in digital reading
rooms has been undertaken. Hospitals with advanced digital
reading equipment are facing an upsurge in complaints of eye
fatigue and strain, blurred vision, headaches and general muscu-
loskeletal issues from radiologists on staff (Kolb, 2005; Prabhu
et al., 2005). A study of 12 radiologists at Tripler Army Medical
Center, Honolulu found that 33% were clinically symptomatic with
either carpal tunnel syndrome or cubital tunnel syndrome, and
symptomatic radiologists spent more time on computers and their
symptoms were mostly experienced when using PACS worksta-
tions that were not ergonomically designed (Ruess et al., 2003).
Before and after evaluation of introducing PACS in 2 large hospitals
in Stockholm, hospital A with 27 radiologists and 68 nurses who
moved to a new building with the introduction of the PACS, and
hospital B with 42 radiologists and 81 nurses where the existing
radiology space was renovated to accommodate PACS, found that
PACS increased the prevalence of seated work postures for more
than 50% of the day, especially among the radiologists where this
347
rose from around 50% to almost 80% in hospital A, and from
around 70% to over 90% in hospital B (Lindbeck and Höglund,
2008). The prevalence of headaches in the past 4 weeks was
high at around 70% in hospital A and in hospital B this increased
dramatically from around 25% to over 60% with PACS, and in both
hospitals over 60% reported very frequent musculoskeletal pain,
with the most affected body regions being the neck/cervical spine,
shoulder, upper arm and lower back. Another survey of 73 faculty
members, fellows, and residents in a PACS-based radiology
department where 68% reported working >8 h per day at a PC or
PACS monitor (55% of faculty members, 80% of trainees) found that
58% reported MSDs (Boiselle et al., 2008). Improvements in MSDs
were reported by 80% of those who received ergonomic work-
stations (n ¼ 55); by 80% of those who underwent ergonomic
training (n ¼ 20); and by 70% of those who received ergonomic
chairs (n ¼ 54). Recent research has found that radiologists spend
almost 6 h reading from PACS monitors and the duration of
reading correlates with reports of headache, eyestrain, difficulty
focusing, and blurry vision (Krupinski and Berbaum, 2009). To
assist with evaluating the ergonomic design of a PACS reading
room, a 39 items checklist was developed to evaluate environ-
mental factors (display screens, input devices, workstation and
workstation accessories, chair and ambient conditions) in the
work environment of radiologists (CDRREC, 2006; Brynjarsdottir,
2006).
3. Healthcare ergonomic programs
General medical and surgical hospitals reported more injuries
and illnesses than any other industry in 2007 (more than 253,500
cases) and injured nurses contribute to about one-fourth of all
workers’ compensation claims and one-third of total compensation
costs (Bureau of Labor Statistics, 2010). More than one-third of back
injuries among nurses have been associated with the handling of
patients and the frequency with which nurses are required to move
them (Krupinski and Berbaum, 2009; CDRREC, 2006). The high
MSD rate for US nurses is compounded by the fact there is a nursing
shortage in this country. Along with the aging of baby boomers and
increased chronic illnesses due to high obesity rates, the US is
seeing a serious shortage of nurses that is expected to continue for
some time. The shortage is expected to increase to 340,000 by the
year 2020 (ANA, 2009). To add to the nursing shortage, it is esti-
mated that 12% of nurses leave the profession annually due to back
injuries and more than 52% complain of chronic back pain
(Buerhaus et al., 2007). In a study of 1505 female healthcare
workers, the prevalence of low back pain was 47% and was related
to pushing and pulling as well as postural factors such as prolonged
standing and bending over. Nurses and nursing assistants were
found to have a higher risk of low back disorders (OR ¼ w2.0)
related to job tasks involving lifting, carrying, pushing and pulling
(Estryn-Behar et al., 1990).
As healthcare costs continue to soar, some healthcare organi-
zations are implementing ergonomics programs to try to contain
costs. Most of the healthcare ergonomics focus to date has been in
the area of safe patient handling and the use of lift equipment. In
2009 the US Senate introduced the Nurse and Health Care Worker
Protection Act of 2009 (S 1788), which would set standards on safe
patient handling and injury prevention. Companion legislation has
been introduced in the US House of Representatives (HR 2381). This
legislation calls for the safe handling of dependent patients and
residents throughout the healthcare system and directs the
Secretary of Labor to issue an occupational safety and health
standard to reduce injuries to patients and all healthcare workers
by establishing a safe patient handling and injury prevention
standard including the use of engineering controls to perform
348 A. Hedge et al. / International Journal of Industrial Ergonomics 41 (2011) 345e351

lifting, transferring, and repositioning of patients and the elimi-
nation of manual lifting of patients (Nurse and Health Care Worker
Protection Act, 2009).
Patient handling is known to cause high MSD rates among
healthcare workers, especially concerning back injuries. Soft tissue
injuries also can arise in many different areas including laundry and
food preparation services, housekeeping, maintenance, pharmacy,
and laboratory settings. However, with the increased use of HIT in
poorly designed workstations, there is an increased risk of UEMSDs
among nurses, physicians and other clinicians. Ergonomics is
important for the safety and well-being of all healthcare workers,
but is often overlooked. With so many more clinicians using
computers than ever before, the design and placement of
computers and related equipment are critical for comfort, safety,
and productivity while also ensuring accuracy. Some clinical
settings have been retrofitted and have improper counter heights;
old equipment, inadequate workspace, improper lighting, and
limited capacity for workspace redesign (Trinkoff et al., 2003). This
underscores the need for a comprehensive ergonomics program in
healthcare organizations. Some healthcare organizations include
ergonomics in their employee safety programs to improve health
and reduce work-related MSDs (Evanoff et al., 1999; James et al.,
2002). But overall, the industry has been slow to adopt ergo-
nomics programs. In addition to injury reduction, incorporating
ergonomics into the design of work environments can ensure
working conditions are optimal for safe, efficient, and effective job
performance. A report on patient safety and workspace design
commissioned by the Institute of Medicine (IOM) summarizes a list
of key ergonomic design principles for healthcare and nursing as
well as solutions for implementing those principles (Table 1)
(Estryn-Behar et al., 1990).
3.1. Benefits of an ergonomics program
A healthcare ergonomics program can help achieve three goals
in healthcare: (1) identify jobs that are likely to cause MSDs; (2)
prioritize existing jobs that are in need of change due to ergonomic
risk factors; and (3) prevent MSDs in future jobs. Given the current
state of the US economy, healthcare administrators may be hesitant
to fund ergonomics programs, however the general duty clause
under section 5 (a) (1) of the Occupational Safety and Health Act
(OSHA) indicates, “Each employer shall furnish to each of his
employees employment and a place of employment which are free
from recognized hazards that are causing or likely to cause death or
serious physical harm to his employees.” (OSHA, 1970). OSHA has
successfully used the General Duty Clause as a basis for citation of
ergonomics hazards in several industries including tire production,
the food industry, and healthcare (nursing homes). Patrick Kapust
with OSHA’s Directorate of Enforcement Programs told attendees at
the 2009 American Society of Safety Engineers’ (ASSE) conference
that the agency issued 19 General Duty Clause citations for ergo-
nomics since 2002. During the same time period, OSHA conducted
4500 ergonomic inspections and issued 640 hazard alert letters on
ergonomics. Companies receiving the letters receive a follow-up
visit from OSHA. There are many benefits of ergonomics programs
besides OSHA compliance. In 1997 the General Accounting Office
(GAO) conducted case studies of five employers (including one
healthcare organization) to learn how elements of ergonomics
programs were being applied and to determine whether or not the
programs were beneficial. It was determined that all five employers
believed their ergonomics programs yielded benefits including
reduced workers’ compensation costs, reduced overall injuries and
illnesses and improved worker morale, productivity, and product
quality (GAO, 1997).
3.2. A business case for ergonomics programs
The results of a financial case study for an ergonomics program
within the Veterans Health Administration (VHA) which spends
approximately $22 million per year in caregiver injuries related to
patient handling showed that implementing an ergonomics
program reduced injuries and annualized savings in medical care
and employee costs estimated at over $200,000 per year and the
rate of injuries decreased significantly and absenteeism from illness

Table 1
Summary of Ergonomic design principles applicable to nursing (Carayon et al., 2003).

Design principles Solutions Examples of application in nursing work

Minimize perception time
Minimize decision time
Minimize manipulation
time
Optimize opportunity
for movement
Minimize need for human
strength
 Visible parts: nothing hidden
 Visual discrimination, using appropriate size and color
 Tactile discrimination, using appropriate texture and size
 Ease the formation of a mental model: visible parts,
minimize number of parts
 Reduce choice reaction time: collocation
of associated items
 Spatial compatibility
 Visual, auditory and tactile feedback
 Ease of manipulation
 Physical affordances and constraints
 Design for transfer of training: e.g., new product or
equipment similar to old
 Ease of access of equipment and materials
 Location of equipment and materials
 Use of mechanical devices
 Eliminating need for human strength
 Larger display fonts on patient monitors and medical
devices that can be read from across the room
 Cardiac monitors using red display for heart rate
 Red alarm knobs
 Sand-paper finishes on door knobs designating no entrance
 Different alarm sounds associated with various medical devices,
i.e. distinct chimes of an IV pump alarm rather than a buzz or a
beeping alarm on a respirator
 Code button and pocket resuscitation device at the end of the
patient’s bed that can be quickly accessed for CPR
 Patient headboards with blood pressure cuffs and suction devices on
both sides of the bed
 Electronic ‘sticky’ buttons on devices and electronic sounds giving
a traditional mechanical ‘switch’ or ‘button’ feel and sound to use
 In-line suction catheters eliminating the need for two persons
during respiratory suction
 Computer simulation and training on new devices prior to use on
the patient floor
 Patient beds showing the degree of elevation on the bedside
by the patient’s bed
 Balance between need to move for patient care duties and need to
stand for recording or for standing at the nursing station
 Patient beds with built-in weight scales
 Beds that rotate from side to side
 Beds with alarms when patients attempt to leave the bed
 Patient gurneys that allow for X-ray or fluoroscopy eliminating the
need for transfer to an X-ray table
 A. Hedge et al. / International Journal of Industrial Ergonomics 41 (2011) 345e351
due to work-related injuries decreased by 18% (Siddharthan et al.,
2005). The payback period for the intervention was calculated at
4.3 years without including the indirect benefits such as increased
employee morale and patient satisfaction and decreased cost due to
recruitment and retention of nurses. The internal rate of return
(IRR) was calculated at 19% over the life of the ergonomics program
of 10 years on the original capital investment of 1.5 million dollars.
3.3. Evidence of positive impact of ergonomic interventions
A prospective intervention study on the impact of ergonomic
programs in 86 healthcare facilities in Ohio, comprised of 73
nursing homes (84.9%), 10 MR/DD (mental retardation or devel-
opmental disabilities) facilities (11.6%), and 3 hospitals (3.5%),
evaluated the impact of installing ergonomic equipment with
ergonomic consultation to reduce MSDs (Fujishiro et al., 2005). For
97% of the sample the researchers gathered at least 1 year of
baseline and 100% of the sample, had at least 1 year of follow-up
data. Results showed that the ergonomic consultation and ergo-
nomic equipment significantly reduced the median MSD rate
which decreased from 12.3 to 6.6 per 200,000 employee-hours
and that this beneficial effect was consistent between the different
facility types.
In Canada, the Occupational Health and Safety Agency for
Healthcare (OHSAH) has reported on projects consisting of multiple
interventions aimed at improving the healthcare workplace (Yassi
and Hancock, 2005). One project looked at the installation of
ceiling lifts in British Columbia and found an 83% reduction in lost
hours from patient handling injuries as well as an increase in
patient satisfaction from 80% to 95% after implementation. OHSAH
has developed a Workplace Health Indicator Tracking and Evalua-
tion (WHITE) database as a means of linking patient adverse events
in parallel with worker health and safety indicators. Ideally this type
Fig. 1. Reference postures for computer work (from ANSI/HFES 100-2007) (Szeto and Sham, 2008).
349
of database will be expanded to include the impact of increased use
of computers in healthcare on patient outcomes as well.
3.4. Elements of effective ergonomic programs
Experts generally agree that effective ergonomics programs
must have a core set of elements to ensure that ergonomic hazards
are identified and controlled to protect workers. NIOSH recom-
mends the following elements be included in ergonomics programs
(NIOSH, 1997):
 management commitment
 employee involvement
 identification of risk factors in jobs
 development of solutions or controls for risk factors
 evaluation of control effectiveness
 training and education for employees
 appropriate medical management
Ergonomics programs can also be modeled on the OSHA
Meatpacking Guidelines or on the AIHA/ANSI Z10-2005, Standard
for Occupational Health and Safety Management Systems (AIHA,
2005).
For HIT implementation the ANSI/HFES 100-2007 standard
(HFES, 2007) recommends neutral postures for either seated or
standing computer work (Fig. 1) and specifies the optimal posture
for seated computer workers as follows:
 Sit in a slightly reclined posture and maintain an open angle at
the elbows, hips, knees.
 Use the chair back to support upper and lower back.
 Thighs approximately parallel to floor.
 Put feet on a foot support/floor.
350 A. Hedge et al. / International Journal of Industrial Ergonomics 41 (2011) 345e351
 Avoid compression at back of knees.
 Adjust armrests so they do not cause shoulder scrunching or
put pressure on arms.
 Vary sitting posture throughout the day.
The standard also requires that any computer input device
surface shall: adjust in height, or a combination of height and tilt, to
allow placement of the input device within the recommended
space; provide adequate leg and foot clearance; and provide
adequate space for multiple input devices (e.g., keyboard and
mouse). Input device surfaces need to accommodate an appropriate
range of height adjustment for users from at least a 5th percentile
woman to a 95th percentile man, which for standing work is
a range from 3600 e4600 (1 me1.17 m) height from the floor to the
keyboard home row, and for sitting use is a range from 2100 to 2800
(53 cme71 cm) height from the floor to the keyboard home row.
Fig. 2 shows the optimal horizontal layout of computer input
devices recommended by the ANSI/HFES 100-2007 standard.
Similarly, the ASTM standard E2502 for Medical Transcription
Workstations (ASTM, 2006) addresses requirements for the
workstation environment, furniture and computer equipment.
4. Telecommuting and healthcare professionals
As healthcare administrators continue seeking ways to reduce
costs and increase productivity, telecommuting among healthcare
employees, such as medical coders, is becoming more widespread
and International Data Corporation (IDC) reports telecommuting
rates are highest in the healthcare industry (Yassi and Hancock,
2005). Additional telecommuting benefits for healthcare adminis-
trators include increased availability of clinic and hospital office
space and increased employee satisfaction. Research has shown
that telecommuting can positively contribute to quality of life for
individuals (Jacobs et al., 1995). Although there is some cost asso-
ciated with setting up a home office, most healthcare establish-
ments can realize an overall reduction in costs for space and
utilities. The increase in telecommuting employees has caused risk
managers and safety directors to raise questions about employers’
responsibility and liability in these home-based work environ-
ments. On February 25, 2000, OSHA issued a Directive on Home-
Based Worksites (OSHA, 2000) which stated that OSHA will not
conduct inspections of employees’ home offices, will not hold
employers liable for employees’ home offices, and does not expect
employers to inspect the home offices of their employees. However,
Fig. 2. Recommended optimal computer input device layout (from ANSI/HFES 100-
2007) (Szeto and Sham, 2008).
employers will continue to be liable for injuries or illnesses caused
by materials, equipment or work processes which the employer
provides or requires to be used in an employee’s home and
employers are also required to maintain records of work-related
injuries and illnesses occurring in the home work office just as they
would in the traditional office environment.
Research on telecommuters shows that work is performed in
various rooms in a house: 30% work in the living room, 27% work in
a bedroom, 22% work in a dining room; 5% work in the kitchen, and
16% work elsewhere in the house (Grozdanovic and Pavlovic-
Veselinovic, 2001). Also, it is possible for teleworkers to work
from neighborhood work centers or from their cars or other loca-
tions and technological innovations are increasingly allowing
location independence to become a dynamic property of the work
process, as well as permitting more sophisticated forms of inter-
action using multimedia communications (Grozdanovic and
Pavlovic-Veselinovic, 2001). To help protect telecommuting
workers from developing MSDs in the home office or neighborhood
work center, ergonomic design considerations for workstations
should follow the US standard (HFES, 2007).
Levels of telecommuting undoubtedly will increase in the future
and ergonomics awareness, training and education in the applica-
tion of basic ergonomics principles can help employees maintain
safe environments wherever they work as a telecommuter.
5. Conclusions
Healthcare is the last major sector of the US economy to
computerize and ergonomics will play an increasingly important
role as the healthcare workplace computerizes to ensure that this
does not result in any increase in the prevalence of UEMSDs. This
review has examined how such computerization affects the nature
of the jobs of healthcare professionals as well as the prevalence of
musculoskeletal disorders for such people. Evidence for the need
for ergonomics has been summarized for a wide range of healthcare
IT applications. It has considered how the changing nature of IT also
may fundamentally change the nature of some healthcare work
allowing this to become location free and increasing the likelihood
that it will be undertaken by telecommuters. Finally, it has
summarized ergonomic design principles from the current stan-
dard as well as other current ergonomics literature. These ergo-
nomic design principles will be of considerable value to the
successful implementation of healthcare IT. Finally, as technology
and network speeds continue to improve then it is highly probable
that there will be more extensive use of teleworking and even
telemedicine for remote diagnosis, surgery and remote care, an area
beyond the scope of this review. However, whatever the setting, if
people are working with computer technology then the well
established ergonomic design principles outlined here will be
important in the design and implementation of these systems to
protect the health of HIT workers and to promote their efficient and
effective performance.
Acknowledgments
We gratefully acknowledge the editorial assistance of Kimberly
Rollings.
References
AIHA/ANSI Z10-2005, Standard for Occupational Health and Safety Management
Systems, 2005.
American Nurses Association (ANA), 2009. http://www.nursingworld.org/.
Andersen, P., Lindgaard, A., Prgomet, M., Creswick, N., Westbrook, J.I., 2009. Mobile
and fixed computer use by doctors and nurses on hospital wards: multi-method
 A. Hedge et al. / International Journal of Industrial Ergonomics 41 (2011) 345e351
study on the relationships between clinician role, clinical task, and device
choice. J. Med. Internet Res. 11 (3), e32.
Asaro, P.V., Boxerman, S.B., 2008. Effects of computerized provider order entry
and nursing documentation on workflow. Acad. Emerg. Med. 15 (10),
908e915.
ASTM 2006. ASTM Standard E2502-06 Standard Guide for Medical Transcription
Workstations, ASTM International. 100 Barr Harbour Drive P.O. box C-700 West
Conshohocken, Pennsylvania 19428-2959, United States. July 1.
Boiselle, M.P., Levine, D., Horwich, P.J., Barbaras, L., Siegal, D., Shillue, K., Affeln, D.,
2008. Repetitive stress symptoms in radiology: prevalence and response to
ergonomic interventions. J. Am. Coll. Radiol. 5 (8), 919e923.
Boothroyd, K., Hedge, A., Effects of an LCD arm on comfort, posture and preference
in an Architectural practice. In: Proceedings HFES 51st Ann Meet, Baltimore,
Oct.1e5 2007, pp. 549e553.
Brynjarsdottir, H. The Cornell Digital Reading Room Ergonomics Checklist: Devel-
opment and Evaluation, MS thesis, Cornell University, 2006.
Buerhaus, P.I., Auerbach, D.I., Staiger, D.O., U.S. Department of Labor, Bureau of Labor
Statistics, BLS Releases 2004e2014 Employment Projections, USDL 05-2276,
www.bls.gov/emp.; “Better Late Than Never: Workforce Supply Implications of
Later Entry Into Nursing.” Hlth Aff., 26 (1) (2007) pp. 178e185.
Bureau of Labor Statistics, 2010. http://www/bls.gov.
Carayon, P., Alvarado, C., Hundt, A., 2003. Reducing Workload and Increasing Patient
Safety Through Work and Workspace Design (IOM commissioned report).
Cornell Digital Reading Room Ergonomics Checklist CDRREC, 2006. Retrieved
August 10 2009. http://ergo.human.cornell.edu/CDRREC.htm.
Dumford 3rd, D.M., Nerandzic, M.M., Eckstein, B.C., Donskey, C.J., 2009. What is on
that keyboard? Detecting hidden environmental reservoirs of Clostridium
difficile during an outbreak associated with North American pulsed-field gel
electrophoresis type 1 strains. Am. J. Infect. Control 37 (1), 15e19.
Estryn-Behar, M., Kaminski, M., Peigne, E., Maillard, M.F., Pelletier, A., Berthier, C.,
Delaporte, M.F., Paoli, M.C., Leroux, J.M., 1990. Strenuous working conditions
and musculoskeletal disorders among female hospital workers. Int. Arch.
Occup. Environ. Health 62, 47e57.
Evanoff, B.A., Bohr, P.C., Wolf, L., 1999. Effects of a participatory ergonomics team
among hospital orderlies. Am. J. Ind. Med. 35, 358e365.
Fujishiro, K., Weaver, J.L., Heaney, C.A., Hamrick, C.A., Marras, W.S., 2005. The effect
of ergonomic interventions in healthcare facilities on musculoskeletal disor-
ders. Am. J. Ind. Med. 48 (5), 338e347.
US General Accounting Office, Worker Protection - Private Sector Ergonomics
Programs Yield Positive Results, August. GAO/HEHS-97e163. GAO, 1997. Report
HEHS-97-163, 1997. Government Accounting Office, Washington, D.C.
Gerbaudo, L., Violante, B., 2008. [Relationship between musculoskeletal disorders
and work-related awkward postures among a group of health care workers in
a hospital]. Med. Lav. 99 (1), 29e39.
Grozdanovic, M., Pavlovic-Veselinovic, S. Framework for Teleworking. TELSIKS 2001.
In: 5th International Conference on Telecommunications in Modern Satellite,
Cable and Broadcasting Service, 2, 2001, pp. 723e726.
ANSI/HFES 100-2007 Human Factors Engineering of Computer Workstations, 2007.
HFES, Santa Monica.
Horii, S.C., Horii, H.N., Mun, S.K., Benson, H.R., Zeman, R.K., 2003. Environmental
designs for reading from imaging workstations: ergonomic and architectural
features. J. Digit. Imaging 16 (1), 124e131. Retrieved September 10 2005 from.
http://www.springerlink.com/media/2g540x5uul7vtjfmhqvl/contributions/g/n/
l/u/gnlua0ajj29cyk91.pdf.
Hou, J.Y., Shiao, J.S., 2006. Risk factors for musculoskeletal discomfort in nurses.
J. Nurs. Res. 14 (3), 228e236.
Jacobs, S., Pelfrey, S., VanSell, M., December 1995. Telecommuting and health care:
a potential for cost reductions and productivity gains. Health Care Superv., 43e49.
James, T., Lamar, S., Alleman, T., 2002. Simple solutions reduce MSDs in hospitals. In:
McCabe, P.T. (Ed.), Contemporary Ergonomics 2002. Taylor and Francis.
351
Kee, D., Seo, S.R., 2006. Musculoskeletal disorders among nursing personnel in
Korea. Int. J. Ind. Ergon. 37, 207e212.
Kolb, G.R., April 2005. Rethinking the radiologist work space. Imag. Econ.
Retrieved May 6 2005 from. http://www.imagingeconomics.com/library/
200504-09.asp.
Krupinski, E., Berbaum, A., 2009. Measurement of visual strain in radiologists. Acad.
Radiol. 16, 947e950.
Lindbeck, L., Höglund, U., 2008. Ergonomic evaluation of picture archiving and
communication system implementations in two X-ray departments. Ergo-
nomics 51 (2), 98e124.
Nielsen, K., Trinkoff, A., 2003. Applying ergonomics to nurse computer
workstations: review and recommendations. Comput. Inform. Nurs. 21 (3),
150e157.
National Institute of Occupational Safety and Health (NIOSH), Elements of Ergo-
nomics Programs, a Primer Based on Workplace Evaluations of Musculoskeletal
Disorders, 1997. DHHS Publication No. 97e117.
Nurse and Health Care Worker Protection Act of 2009, Bill # H.R. 2381 and S 1788.
Occupational Safety and Health Administration (OSHA) Act of 1970.
Occupational Safety and Health Administration (OSHA) 2000: a review of compli-
ance issues, 2000.
Palenik, C.J., Hughes, E.A., 2008. Microbial contamination of computer keyboards
and mice present in dental clinics. Am. J. Infect. Control 36 (5), E23eE24.
Po, J.L., Burke, R., Sulis, C., Carling, P.C., 2009. Dangerous cows: an analysis of
disinfection cleaning of computer keyboards on wheels. Am. J. Infect. Control 37
(9), 778e780.
Prabhu, S.P., Gandhi, S., Goddard, P.R., 2005. Ergonomics of digital imaging. Br. J.
Radiol. 78 (931), 582e586.
Ruess, L., O’Connor, S.C., Cho, K.H., Slaughter, R., Husain, F.H., Hedge, A., 2003. Carpal
tunnel syndrome and cubital tunnel syndrome: musculoskeletal disorders in
four symptomatic radiologists. Am. J. Roentgenol. 181, 37e42.
Siddharthan, K., Nelson, A., Weisenborn, G., 2005. A business case for patient care
ergonomic interventions. Nurs. Adm. Q. 29 (1), 63e71.
Smith, D.R., Wei, N., Zhang, Y., Wang, R., 2006. Musculoskeletal complaints and
psychosocial risk factors among physicians in mainland China. Int. J. Ind. Ergon.
36, 599e603.
Szeto, G.P.Y., Sham, K.S.W., 2008. The effects of angled positions of computer display
screen on muscle activities of the neckeshoulder stabilizers. Int. J. Ind. Ergon.
38, 9e17.
Trinkoff, A.M., Lipscomb, J.A., Geiger-Brown, J., Storr, C.L., Brady, B.A., 2003.
Perceived physical demands and reported musculoskeletal problems in regis-
tered nurses. Am. J. Prev. Med. 24 (3), 270e275.
Ventres, W., Kooienga, S., Vuckovic, N., Marlin, R., Nygren, P., Stewart, V., 2006.
Physicians, patients, and the electronic health record: an ethnographic analysis.
Ann. Fam. Med. 4 (2), 124e131.
Whittemore, D., Moll, J., 2008. COWs WOWs, oh my! Focusing on the needs of
nurses can help hospital IT departments make the best technology decisions
and improve care giving at the bedside. Health Manag. Technol. 29 (7), 32e34.
Wilson, A.P., Hayman, S., Folan, P., Ostro, P.T., Birkett, A., Batson, S., Singer, M.,
Bellingan, G., 2006. Computer keyboards and the spread of MRSA. J. Hosp.
Infect. 62 (3), 390e392.
Wilson, A.P.R., Ostro, P., Magnussen, M., Cooper, B., 2008. Laboratory and in-use
assessment of methicillin-resistant Staphylococcus aureus contamination of
ergonomic computer keyboards for ward use. Am. J. Infect. Control 36 (10),
e19ee25.
Yassi, A., Hancock, T., 2005. Patient safety - worker safety: building a culture of
safety to improve healthcare worker and patient well-being. Healthc. Q. 8,
32e38.
Yen, K., Shane, E.L., Pawar, S.S., Schwendel, N.D., Zimmanck, R.J., Gorelick, M.H.,
2009. Time motion study in a pediatric emergency department before and after
computer physician order entry. Ann. Emerg. Med. 53 (4), 462e468.