Electronic Health Record Usability and Patient Safety: Risks and Mitigation Strategies

The consequences of suboptimal electronic health record (EHR) usability are significant. First, poor EHR usability has direct patient safety consequences since poorly designed, developed, and implemented technology can promote certain types of errors that result in patient harm. Second, inadequate usability contributes to clinician burnout.

BY JESSICA L. HOWE, A. ZACHARY HETTINGER, AND RAJ M. RATWANI

Burnout has been associated with increases in the likelihood of medical error, contributes to clinicians leaving medicine, and even increases risk of clinician suicide.²

EHRs are used by most healthcare facilities in the United States and serve not only as the digital record of patient care, but also as the primary digital platform for clinicians to deliver care. For example, medications, diagnostic images, laboratory tests, and procedures are almost always ordered electronically through computerized provider order entry (CPOE) and the results from these tests are generally presented to the physician in the EHR. EHR technology has undergone rapid adoption because of the nearly $40 billion investment from the federal government through the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act.

Numerous benefits have been realized because of this technology. Certain patient information is much more accessible than in the days of paper. There has been a reduction of some types of mistakes, such as medication errors due to illegibly written prescriptions. Clinical decision support embedded in the EHR has prevented drug allergy reactions and other issues that used to occur with paper systems.

There are also recognized challenges associated with EHRs. One of the most prominent challenges has been with the usability of EHR technology.³ Usability refers to the ability for clinicians to use this technology efficiently, effectively, and satisfactorily. The poor visual display of information is an example of suboptimal usability. In one instance, when an emergency medicine physician was placing an order for Tylenol (acetaminophen) for a male patient, over 80 different options for Tylenol appeared in the EHR, many of which were not relevant for this patient such as children’s Tylenol and women’s Tylenol.⁴ Example videos from actual EHR products are available at www.EHRSeeWhatWeMean.org.

Usability involves interface design that follows scientifically grounded human factors or principles, such as the types of colors, fonts, and icons to use. Importantly, it also includes designing, developing, and implementing the technology in a way that supports the cognitive needs of clinicians. The cognitive support aspect of usability requires a deep understanding of clinical needs in context. For example, knowing how clinicians reason with information about a patient’s laboratory results should inform how this information is displayed. The display of information can either support or hinder the clinician’s reasoning processes. EHR usability is shaped by the vendor’s design and development, but also by the healthcare facility’s decisions around configuration and customization of the technology, and by federal policies that may impact design decisions.

Reducing the risks associated with suboptimal EHR usability requires understanding current usability challenges and employing resources and strategies to improve usability shortcomings.

EHR usability and safety challenges

In previous research, we qualitatively analyzed free text narratives within patient safety event reports from more than 500 healthcare facilities to identify EHR usability issues associated with patient harm.⁵ Starting with a database of more than 1.7 million reports, we used a conservative approach to identify EHR usability-related events by searching for events that
1. explicitly mentioned the name of a frequently used EHR vendor, and
2. were reported to have resulted in patient harm.

This resulted in 1,956 reports and of these, 557 reports had explicit language indicating an EHR usability issue was associated with the safety event. We then categorized these events by the type of usability process and the clinical process impacted. The three most prominent usability issues were data entry, alerting, and interoperability.

Data entry—This usability issue occurs when the process for a clinician to enter desired information in the EHR is difficult or is not possible. These issues were associated with 27% or 152 of the 557 reports that were analyzed. An example of a data entry usability and safety issue is an ambiguous interface that leads to confusion over the entry of a patient’s height and weight, resulting in a patient’s weight being entered in the height field and the patient’s height being entered in the weight field. This could lead to serious weight-based dosing errors and patient harm.

Alerting—This usability issue occurs when EHR alerts or other feed-back are inadequate because they are absent, incorrect, or ambiguous. These issues were associated with 22% or 122 of the 557 reports that were analyzed. For example, there are instances where a patient may have a documented allergy to a medication, yet, when that medication is accidentally prescribed to the patient, the allergy alert is not triggered. This could lead to the patient receiving a medication he/she is allergic to and could result in an adverse drug reaction.

Interoperability—This usability issue occurs when EHR interoperability is inadequate within components of the same EHR or from the EHR to other systems, hindering the communication of information. Interoperability describes the ability of computer systems and applications to exchange information and operate in conjunction with each other. Poor interoperability issues were associated with 18% or 102 of the 557 reports that were analyzed. For example, a patient may be treated in the emergency department (ED) with medication orders placed in the EHR, but in some circumstances if the patient is admitted and transferred to another part of the hospital, the medication orders placed in the ED are not visible to receiving clinicians even within the same healthcare system. This leads to the potential for duplicated medication errors and other risks.

Most of these usability and safety issues occurred during medication, lab, or imaging order placement (213 of 557 reports, 38%) and medication administration (207 of 557 reports, 37%). Similar analyses have been conducted with medication-related patient safety event reports in pediatric settings⁶ and with legal claims data.⁷ Similar usability issues as those described here were also found in those analyses.

Resources and strategies to improve EHR usability and safety

While healthcare facilities should always work with their EHR vendor when usability issues are identified, there are several actions they can take to address usability challenges independent of vendor involvement.

Assess EHR usability with test cases—Identifying the specific usability and safety risks in healthcare facilities’ EHR is the first step to addressing usability challenges. To identify these challenges, test cases, which are clinically relevant scenarios that a clinician completes in the EHR, can be used to pinpoint specific usability shortcomings. For example, a test case may involve a clinician documenting a medication allergy and then deliberately ordering that medication to see if the EHR triggers an alert at the right time and in a format that is meaningful to the clinician. Based on the usability categories described above, as well as others, a set of test cases has been developed for use by healthcare facilities to assess EHR usability. These test cases are available in a report, Ways to Improve Electronic Health Record Safety, published by The Pew Charitable Trusts, American Medical Association, and MedStar Health.

Leverage usage data to identify usability challenges—Most EHRs collect usage data that provide detailed information on user interactions with the EHR, such as what types of orders were placed, when they were placed, if an alert was triggered, if an alert was dismissed, and if orders were cancelled. These usage data provide a view into how clinicians are using the EHR and, if analyzed appropriately, can be used to identify aspects of the EHR that may be posing usability and safety challenges.⁸ For example, looking at the usage data, one may be able to determine if certain alerts, such as those for drug allergies or drug interactions, are frequently dismissed. Identifying these types of patterns provides context for where improvement efforts should be focused.

Make usability improvements using the usability change package—Many healthcare organizations, especially smaller hospital-and ambulatory-based practices, do not have dedicated staff to investigate EHR usability issues. There are, however, several resources that have been developed by government agencies and nonprofit organizations that are committed to improving the usability of EHRs. As a result, the Office of the National Coordinator created a usability change package that covers basic concepts of usability, provides test scenarios, and summarizes resources that healthcare organizations can use to investigate and fix EHR usability concerns. The change package, ONC Change Package for Improving EHR Usability, is available from the Office of the National Coordinator for Health Information Technology.

Optimize the potential of EHRs

EHRs have already provided many benefits and hold tremendous poten- tial to transform the way care is delivered. However, recognizing current EHR usability challenges that pose patient safety hazards is important to keeping patients safe and reducing risk. Focusing on the types of usability issues described here and using the provided resources and strategies is a starting point to For related information, see www.medicalhumanfactors.net. improve this valuable technology.

References

1. J.L. Howe et al. Electronic health record usability issues and potential contribution to patient harm. J Am Med Assoc 319(12), 2018: 1276-1278.
2. M. Panagioti et al. Association between physician burnout and patient safety, professionalism and patient satisfaction: A systematic review and meta- analysis. J Am Med Assoc Internal Medicine 22(6), 2018: 1317-1331.
3. J.L. Howe et al. Electronic health record usability issues and potential contribution to patient harm. J Am Med Assoc 319(12), 2018: 1276-1278; R.M. Ratwani et al. Electronic health record usability: Analysis of the user-centered design processes of eleven electronic heath record vendors. J Am Med Informatics Assoc, 22(6), 2015: 1179-1182; R.M. Ratwani et al. A usability and safety analysis of elec- tronic health records: A multi-center study. J Am Med Informatics Assoc 25(9), 2018: 1197-1201; R.M. Ratwani et al. Identifying electronic health record usability and safety challenges in pediatric settings. Health Affairs 37(11), 2018: 1752-1759; M.L. Graber et al. Electronic health record-related events in medical malpractice claims. J Patient Safety 15(2), 2019: 77-85.
4. M. Ratwani et al. A usability and safety analysis of electronic health records: A multi-center study. J Am Med Informatics Assoc 25(9), 2018: 1197-1201.
5. J.L. Howe et al. Electronic health record usability issues and potential contribution to patient harm. J Am Med Assoc 319(12), 2018: 1276-1278.
6. R.M. Ratwani et al. Identifying electronic health record usability and safety challenges in in pediatric settings. Health Affairs 37(11), 2018: 1752-1759.
7. M.L. Graber et al. Electronic health record-related events in medical malpractice claims. J Patient Safety 15(2), 2019: 77-85.
8. D. Classen et al. An electronic health record-based real-time analytics program for patient safety surveillance and improvement. Health Affairs 37(11), 2018: 1805-1812.