7 EHR usability, safety challenges—and how to overcome them

Tanya Albert Henry , Contributing News Writer

At their best, EHRs can give physicians data and tools to care for their patients. But sometimes, EHR design, customization or configuration can contribute to patient harm. Meanwhile, a growing body of research is quantifying how EHRs add to physicians’ clerical burdens.

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For example, a 2018 report from the AMA, Pew Charitable Trusts and Medstar Health, Ways to Improve Electronic Health Record Safety, identified shortfalls with EHR usability, implementation and testing and outlined how to improve usability and safety across the continuum—from development to the post-implementation of EHRs.

The three organizations reviewed the medical literature and convened an expert panel of physicians, nurses, pharmacists, EHR vendors, patients and health IT experts. Together, they developed recommendations on best practices to follow throughout an EHR’s life cycle.

The recommendations covered factors such as safety culture, product design and development, acquisition, customization and configuration, implementation and system upgrades, and training and provides EHR developers and health care providers with specific areas of opportunities for improvement within each EHR life cycle stage. For example, health care organizations should “develop clear justification and use cases for why customizations should be made” and “allow clinicians and subject-matter experts to shape usability and safety design and testing.”

“Adherence to these recommendations by EHR developers and health care providers can reduce the likelihood of unintended patient harm from clinician use of this technology,” the report said.

After analyzing 557 reports that physicians and other health professionals submitted, researchers identified seven safety and usability challenges physicians should be on the lookout for when they use EHRs in their practice.

Data entry. A clinician’s work process may make it hard or impossible to appropriately enter the desired EHR data. One case researchers analyzed showed that a clinician chose the wrong frequency for a drug to be administered because the clinician didn’t realize that the order in which the options were populated in the EHR had changed.

Alerting. EHR alerts or other feedback from the system are sometimes inadequate because they are absent, incorrect or ambiguous. For example, a report showed that even though a patient’s gelatin allergy was listed in the EHR, a clinician wasn’t alerted to the allergy while prescribing a medicine.

Interoperability. Communication of information in an EHR may be hindered because interoperability is inadequate within components of the same EHR or from the EHR to other systems. In one case, clinicians couldn’t access laboratory results for a hospital patient from records held in a different part of the hospital.

Visual display. Clinicians may find it hard to interpret information because EHR displays are confusing, cluttered or inaccurate. For example, a clinician tried to order 3.125 mg of a medication, but the EHR listed only a 6.25 mg prescription, with a 3.125 mg dose listed in small print, confusing the clinician.

Availability of information. Clinically relevant information is hindered because it is entered or stored in the wrong location or is otherwise inaccessible in the EHR. For example, a hospital lab staffer couldn’t access a section of a patient’s health record where the clinician ordered diagnostic tests; consequently, the tests weren’t performed.

System automation and defaults. The EHR automates or defaults to information that is unexpected, unpredictable or not transparent to the clinician. For example, a clinician ordering an anticoagulant tried to start the dosing at a set time, but the date automatically defaulted to the following day.

Workflow support. The EHR workflow is not supported due to a mismatch between the EHR and the end user’s intent. In one case, a physician ordered diagnostic tests and included instructions for the lab in a special instructions field, not knowing that the lab staff couldn’t see that information. Consequently, the tests weren’t conducted.

The report recommended that health care providers and EHR developers use safety-based, rigorous test case scenarios that are outlined in the report to detect and correct problems and help avoid patient safety issues similar to those reported above.

For more details on this analysis by researchers at MedStar Health’s National Center for Human Factors in Healthcare, read their JAMA study, “Electronic Health Record Usability Issues and Potential Contribution to Patient Harm.”

On another front, a growing body of evidence is quantifying the EHR burdens practicing physicians know all too well and that have contributed to the doctor burnout crisis. For example, one study published in JAMIA found that for every eight hours that office-based physicians have scheduled with patients, they spend more than five hours in the EHR.

The AMA’s Electronic Health Record Use Research Grant Program began in 2019 to identify patterns in EHR use that may detract from patient care. The AMA has awarded more than $2 million in grants to 26 organizations over the years to study a variety of EHR-use topics.

“Burdensome EHR systems are a leading contributing factor in the physician burnout crisis and demand urgent action,” Christine Sinsky, MD, the AMA’s vice president of professional satisfaction, said earlier this year. “The research supported by the AMA grant program builds the evidence base to help change EHR technology into an asset to medical care, and not a demoralizing burden.”