Top EHR Usability Challenges and How to Overcome Them

Objective EHR usability issues remain

When health systems, EHR users, or researchers examine EHR usability challenges, they often look at objective criteria, such as the font or color of the display.

“I'm very influenced by Raj Ratwani's way of thinking about EHR usability,” said Julia Adler-Milstein, PhD, researcher at the Center for Clinical Informatics and Improvement at the University of California, San Francisco.

“There are objective principles of usability relayed into font size and color that any type of technology should have. However, we have not done a great job of making sure that EHRs meet those objective usability criteria,” Adler-Milstein continued.

Ratwani, PhD, director of MedStar Health Human Factors Center, reported roughly 40 percent of EHRs had an issue that could potentially lead to patient harm and about 786 hospitals and 37,365 individual providers may have used EHRs with potential safety issues based on required product use reporting.

Common EHR usability issues can put crucial patient safety issues, such as drug dosing, at risk.

“In this particular EHR, when a dose was entered, the decimal point was actually removed from the entry,” Ratwani explained. “If a physician were to type in an order for 2.5 milligrams of a medication, what would actually be entered and processed by the EHR as 25 milligrams. This could lead to a significant overdose. Those are the kinds of issues that were occurring.”

Patient safety challenges typically come from EHR systems that are poorly designed, developed, or implemented. These challenges also stem from a cluttered interface or a complex medication list. Encountering a cluttered list can lead a clinician to select the wrong medication.

Data entry is another major usability issue. EHR users want that process to be as clean and consistent as possible.

While EHR usability directly impacts patient safety, it can also lead to clinician burden.

A complex interface can force the clinician to interact heavily with the EHR, which can result in added clicks and scrolls. Click fatigue increases the chances of error and clinician burnout.

However, Ratwani and other health IT professionals recommended strategies to mitigate these objective concerns.

Developing an EHR reporting program is crucial to developing EHR usability improvements.

“There's a reporting program for medical device issues and a reporting program for vaccines and for medications,” Ratwani explained. “We need the same thing for health information technology so that when a clinician or even a patient sees potential safety issues, there's a central reporting program where they can report this issue and then people can rapidly analyze those and communicate that information out to the community.”

To make an EHR reporting program conceivable, Ratwani suggested the elimination of gag clauses.

“Gag clauses prevent clinicians from openly sharing screenshots and other information on their EHR products,” Ratwani said. “Without being able to share that, we wouldn't be able to actually identify these issues very broadly.”

Ratwani also wanted to guarantee accurate and thorough certification testing.

“Some of the test case scenarios that are used to assess or evaluate the HR products can be quite artificial and they don't actually represent the types of cases that our clinicians are going through on a daily basis,” Ratwani continued. “If you have this less rigorous testing being done during the certification process, the product won’t be designed optimally or developed as it could be.”

Addressing cognitive matters

While Adler-Milstein acknowledged the objective EHR issues, she has recently looked at the cognitive nuances of the EHR system. This means the change in EHR usability logic from user to user.

“By far, the most challenging usability issue is the notion of cognitive support,” Adler-Milstein said. “Is the EHR supporting the diagnostic reasoning process and the logical work flow that a given person would want to undertake?”

Adler-Milstein said this is a much tougher fix because it is a mix of both an individual and context-dependent resolution.

“For example, a user can easily say, ‘Well, is that in 12-point font?’ That's easy to solve. But to say, ‘Did we show you the type of information in a format that made it easy for you to figure out what was going on with the patient?’ That's where I think we really struggle because there's so much heterogeneity in what that looks like,” Adler-Milstein explained.

“I do not even think there is a solid correct answer to that question,” she said. “It may be that two different clinicians actually need the same information presented to them in two different ways because of their individual characteristics, their specialty, or any number of other factors. That's just an overall usability challenge that we face.”

Quality EHR training is essential to provider users, especially those new to the technology. An effective EHR training program can improve EHR usability which also reduces the likelihood of clinician burden and boosts satisfaction.

While EHR training programs are becoming more prevalent at the collegiate level, Adler-Milstein recommended training programs include EHR informatics.

“I don't think we're introducing clinicians to the topic of the EHR informatics as a discipline, as a consistent part of training, yet it's really important,” Adler-Milstein said.

Integrating EHR informatics into a training course will allow users to understand EHR design and it will provide context to the intricacies of the technology.

“Users need to understand the billing and regulatory requirements,” Adler-Milstein explained. “Users need to understand that the data that goes into the EHR is used for many purposes, including quality measurements and public health reporting.”

It is very difficult to fully understand the EHR without that context, Adler-Milstein asserted.

Furthermore, she often describes the EHR as serving many masters -- like the folks on the revenue cycle side of things -- and clinicians are just one of those many masters.

“Users need some understanding of those other masters and then that will help them at least start to understand it as a different type of tool that needs to be able to support many different use cases beyond direct patient care,” she continued.  

“It is just having that appreciation and understanding. Then, trying to think about what does good EHR use look like in the context of team-based care and how can we be more thoughtful about communication, division of labor and responsibilities? Who does what?”

Adler-Milstein also stressed the importance of discussing and talking to colleagues about how they complete their work and asking the most important things that they’ve learned about using the EHR.

“The more thought given as opposed to just throwing them into situations,” Adler-Milstein continued.

“We give users a little bit of training on the basics but we don't really talk about the broader issues about how the EHR is being used and how to improve its use over time, especially in the context of team-based care.”

David West, MD, medical director of health informatics at Nemours Children’s Health System, echoed Adler-Milstein’s sentiments that not all users are the same and health systems have to adapt to that line of thinking.

“In an application that strives to bring about standard methods and standard models, usability that tries to force one way of doing things can often be quite challenging and not necessarily consistent with the strengths of the users or the needs of individual patients,” West explained. “Trying to create the adaptability and usability that's appropriate for each setting has been one of our bigger challenges.”

Over time, the EHR system can eventually create unintended consequences, but those consequences could ultimately be reconciled.

“EHRs are never something that an individual can simply pick up at the store,” West said. “The technology always requires training and engagement, and organizations have to devote time, resources, and bandwidth from positions so that they can adequately acclimate to the new workflows and the new ways of doing things. I think sometimes we give short shrift to that kind of preparation in our training and onboarding models in our ongoing engagement.”

At Nemours, West encounters young clinicians or EHR users who assume everything should be on their smartphones, including full EHR access.

“No, we're not there yet,” West explained. “We need to teach them why that's not there yet. Some of the complexities that are involved in the EHR, I don't get much resistance on that point, but I have had people who have expressed that as a wish list kind of thing, if I could just carry around my phone and do everything on that, that would be great. But we can do a lot on our phones. It's not like we can't do anything, but you can't do everything.”

To aid EHR usability problems at Nemours, West and his team are available through their centralized help desk.

“We have a direct entry method channel for suggestions and reporting issues that can be accessed right from Nemours’ homepage or by phone call,” West explained. “I have a team of physician informatics specialists that we refer to as the PHIT Team.” PHIT standing for physicians informatics.

“Physicians can reach out to report or suggest problems or enhancements. We try to engage physicians and communicate feedback in the way that they want to hear it.”

Once the PHIT Team is contacted, they meet with the user to make her aware or teach her a new functionality that could fix the specific workflow issue.

“It is rare to actually go directly to the vendor, but there are certainly a set of issues that we do take to the vendor, but that's the exception and not the rule. Most of the items that we look for are within our own definitions and does not require customization or new code. We just have to configure the system appropriately.”

Tackling EHR alert fatigue

While EHR users come into contact with usability issues from time to time, Alan Weiss, MD, chief medical information officer at BayCare Health System in Florida, pointed at EHR alerts as one of their most common usability interferences.

“If an EHR system has alerts that fires too often to providers, it can impair the work that they're doing,” Weiss said. “As opposed to being an add on for the most important safety issues, having alerts that fire too randomly, don't seem to help. Those can really impede both the physician’s and pharmacist’s workflow.”

Over the last three years, Weiss and his team have been on a journey to help refine and decrease the number of EHR alerts. It was his goal to cut down the number of alerts that do not make clinical sense and refine the ones that are not appropriate.

“When this project started about three years ago, we had roughly 23 million alerts firing per year,” Weiss noted. “Some pharmacists were getting them several times a minute and some providers were getting several alerts per hour. We went through and assessed the ones that seemed to be firing too much and weren’t as useful. We tried to understand if we could retire them or refine them in some way to make them more accepted by our users.”

Weiss said after his team encountered 23 million alerts three years ago, their EHR system is now firing 18 million alerts per year, which is a major improvement. This year, the goal is to target another 3 to 4 million EHR alerts.

“It's all refinement,” Weiss explained. “What we're finding is that these were just noise in the background that stopped the provider from doing her work, and it really impeded their acceptance of the EHR system. It made it seem like the system was not as smart as we wanted it to be.”

Weiss said his team added more intelligence to the alerts. They analyzed the signals and made them active.

“Now, the alerts don’t just tell the user something, it adds an action part to it, where the user can take action from inside of the alert to adjust whatever's going on inside of it. Now, we have providers that are no longer troubled by the alerts, but the alerts can help the user do something to improve quality, safety, and responsiveness to patients.”

This effort to cut down alerts and enhance usability will continue for a long period of time, Weiss said. But cutting down the number of alerts in such a drastic fashion means that the ones that do trigger are the ones that the user can focus on.

“Once again, it's the adjustment of the noise so that providers can really focus on the important things,” Weiss continued.

Whether an individual is a clinician, a chief information officer, or a health IT researcher, EHR usability issues go hand in hand with EHR optimization and the evolution of technology. It takes a mix of EHR training and a total team effort of health IT professionals to mitigate these complications.