EHR Usability: Addressing the "(I Can't Get No) Satisfaction" Sentiment

Raj M. Ratwani, PhD

The usability of electronic health records (EHRs)—the extent to which this technology can be used efficiently, effectively, and satisfactorily—continues to be a frustration and challenge for most physicians across the US. Although many physicians do not want to go back to paper records, they are often dissatisfied with the usability of their EHR.

Poor EHR usability has 2 major consequences. First, it can contribute to physician burnout, which can lead to physicians leaving medicine, and has negative physical and psychological consequences. Second, poor EHR usability can directly and indirectly lead to patient harm. For example, a cluttered medication list that is difficult to read and interpret can result in the physician ordering the wrong or a duplicate medication. Further, a physician with burnout is more likely to make a medical error which may result in patient harm.

Usability also encompasses how error tolerant a technology is, i.e., how resilient a system is to human error. A poorly designed EHR interface, therefore, is by definition prone to errors. The care team is left responsible for identifying and correcting these errors before they potentially harm patients.

EHR usability challenges have not gone unnoticed. A series of articles by Fortune magazine and Kaiser Health News has brought mainstream attention to EHR usability and safety challenges. Several stakeholders, including policymakers, EHR vendors, researchers, clinicians, and patients, have created initiatives to address the problem. Despite these efforts, findings of 2 recent studies of EHR usability satisfaction showed that things may be worse than many stakeholders care to acknowledge—and are not improving.

Recent studies we conducted, with our respective research teams, underscore this reality. A study in Mayo Clinic Proceedings (Melnick et al) found that physicians rate satisfaction with EHRs they use in clinical practice in the bottom decile of all technologies. That score is associated with a letter grade of “F”. Further, they found a strong “dose-response relationship” between physicians’ perception of their EHR system’s usability and the odds of burnout.

Techniques to Identify and Address EHR Usability Challenges Fueling Low Satisfaction

Edward R. Melnick, MD, MHS

A study in JAMA Network Open (Gomes and Ratwani) analyzed vendor-reported measures of EHR usability satisfaction. The team found that, although vendor measurements were in a satisfactory range, there has been no improvement in satisfaction over the past 2 years. In fact, for many widely used EHR products, usability satisfaction went down. With EHR usability having major consequences for patients and physicians and indicators that usability improvement efforts may not be having an immediate impact on products currently implemented, what can be done to improve EHR usability satisfaction right now? Here are 3 techniques to better understand the specific challenges that may be driving EHR dissatisfaction in your practice setting and how you can use this information to make improvements. The techniques described below can be used by large hospital systems as well as small physician practices and can be applied by physicians, safety and quality experts, and/or information technology professionals.

1. Leverage EHR user data to identify suboptimal physician interactions. Healthcare facilities should assess the EHR user audit log that provides data on the specific EHR interactions and time to complete tasks . For example, medication ordering tasks user data can be analyzed to determine whether physicians are searching for specific medications by using the search field, a “favorites” list, or an order set. Understanding the specific types of interactions and time to complete tasks will help identify which processes are more or less efficient and which physicians are engaging in those processes.
2. Observe your physicians using the EHR in their clinical practice and you will learn more than you ever imagined. We often have an idealized view of how work is performed, and it is often drastically different from how work is actually performed. EHRSeeWhatWeMean.org has opened many eyes to the types of usability challenges faced by physicians on a regular basis, such as a physician being presented with 86 different options when ordering Tylenol. Directly observing physicians using the EHR to complete their actual clinical duties will support identification of specific EHR inefficiencies and physician frustrations. In one of our clinical practices, observation allowed us to recognize that it took >20 clicks to order blood cultures. We were then able to create a more rapid pathway for that order.
3. Use interviews and surveys as another method to identify pain points and their scope. Sometimes the best way to identify EHR issues contributing to low physician satisfaction is to simply ask the physician. Conduct interviews with physicians and ask open-ended questions about EHR functions and workflows that are most challenging and how these challenges can be addressed. Interviews are excellent for gathering in-depth information. Surveys can be used to reach a wider group. One strategy is to conduct a few interviews to identify major pain points, and then use this information to construct surveys that can determine their prevalence.

These techniques are intended to help identify specific EHR usability satisfaction challenges which may stem from the design and implementation of the EHR itself, physician knowledge of how to effectively use the EHR, and other sources.

Once specific issues have been identified, there are several actions you can take to address these issues. First, you can identify EHR interaction best practices from your physicians who are spending less time on the EHR compared to their peers. These physicians may have figured out shortcuts and optimal paths to complete certain tasks. This knowledge should be spread to all physicians.

Second, you can use the “ONC Change Package for Improving EHR Usability” to see if specific EHR improvements can be made. Third, talk with other healthcare facility sites that use the same EHR to determine whether they have similar issues and how they have addressed them. Finally, let your EHR vendor know of the specific challenges, and they may be able to address them or provide guidance on who else could help.

Although there are EHR usability challenges, tremendous value has already been realized from this technology, and there is much more to come. Any technology transition of this size, which is arguably unprecedented in medicine, is going to ignite issues that need to be navigated. The important part is that all stakeholders recognize these issues, acknowledge the need for improvement, and actively work to implement solutions. Every patient stands to benefit with better technology, and physicians can get some satisfaction from its optimization.

Raj M. Ratwani, PhD, is the director of MedStar Health National Center for Human Factors in Healthcare. Edward R. Melnick, MD, MHS, is an assistant professor in the Department of Emergency Medicine at Yale University School of Medicine. The presented analysis reflects their views, not necessarily those of the publication.

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