How to Improve EHR Usability to Ensure Better Patient Safety

By now, it has become clear that EHR usability is a complex aspect affecting the tool’s work and the efficiency of medical professionals handling it. But that’s not all. Poor EHR usability can also threaten patients’ health. According to a 2019 study published in JAMA, about 40% of ONC-certified EHR products had usability issues that can cause patient harm. How can medical providers mitigate these risks by improving EHR usability? Let’s figure it out.

EHR usability issues that jeopardize patient health 

The researchers single out a range of EHR usability issues that may lead to patient harm. Among them are:

• A cumbersome interface
• Incomprehensive visual display
• Inconvenient data entry
• Lack of relevant workflows

What is more, the above-mentioned issues can be interconnected. For example, a bulky interface can make it difficult for a user to find what they are looking for, while a cluttered visual display can confuse users, causing data entry errors. Also, EHR processes’ misalignment with hospital workflows can result in doctors not receiving certain alerts and consequently, health complications in patients.

While not many EHRs have such a destructive combination of issues, separate usability issues are quite common in EHRs. So how can they affect patients’ health? Let’s consider some real-life examples.

How EHR usability issues harm patients: viable examples

In December 2021, researchers from MedStar Health, a non-profit healthcare organization, published their report featuring EHR usability impact on patient safety. The researchers collected feedback from emergency room specialists across four large US hospitals. The three most commonly discussed EHR usability topics were workflow support (33.5% of comments), visual display (20 %), and data entry (14.4%). We’ll consider the frequent issues with those usability aspects and their potential effect on patient health.

Lack of workflow support

To ensure patients’ safety, clinical workflows are stringently consecutive, i.e. one step can only be performed after another one. While this approach is reasonable in day-to-day care situations, it can threaten a patient’s life in case of an emergency.

To trigger some EHR functions, clinicians have to fill in specific data fields, and sometimes it delays care. For instance, the EHR system in a medical facility can block record creation for newborns in case their Apgar test results or their weight are missing. This configuration delayed emergency blood transfusion for a girl. In the end, clinicians managed to find a workaround and placed the order for blood using the health record of the girl’s twin brother. The case was described in the research paper by Pew Charitable Trust.

Visual display issues

The way critical information is displayed in the EHR can also be confusing, and at times it can go far beyond harmless misunderstanding and affect the patient’s treatment regimen and in the end, health. For instance, in a recent publication by JAMIA, researchers looked into visual display problems in modern EHRs. The team offered clinicians from two hospitals to evaluate the tools’ usability, answering 46 questions. Surprisingly, three identical visual display issues were detected in both systems, such as excessive search results (10+), its illogical organization, and the use of generic medication names without mentioning their brand names. In terms of patient security, these issues may result in clinicians’ overload and erroneous drug prescriptions.

Display-related issues in EHR also often affect patients in surgical care. Using EHR, medical specialists can set up medication orders in advance, according to the established workflows. In surgical care, the patient’s location changes frequently, so the EHR solution blocks some medication orders. Doctors and nurses at the receiving department or ward may miss those “blocked medications” and relevant care tips. In one case, in a large mid-Atlantic care facility, a patient was erroneously transported back to the operating room, because an EHR blocked the drug order for an antifungal medication, which the clinicians didn’t know about due to faulty visual display settings. It put the patient at risk of prolonged infection.

Inconsistent data entry

Finally, clinical data entry into an EHR system can also become a threat to patient safety. The problem is that not all EHRs support exclusively the metric system, which is the standard in medicine. Some also let clinicians and nurses enter measurements in units traditionally accepted in the US – inches, pounds, and so on. Such an approach can lead to detrimental consequences for patients.

Entering data in the wrong units can lead to serious medication errors, such as patient overdosing or even death. For instance, a clinician erroneously entering weight in pounds in the EHR where kilos is the standard risks a patient’s life. Such a mistake can result in doctors administering a double dose of the medication. To prevent such incidents, EHR tools need to clearly enlist the appropriate measurement units and immediately notify users if a wrong unit was used.

How to solve EHR usability issues

Luckily, the above-mentioned usability issues and patient risks they involve can be mitigated via EHR optimization. Here are the basic tips to follow:

1. 1. Reconsider usability tests. Quite often, it’s not the actual users – clinicians and nurses — who test EHRs, but third-party usability experts with no knowledge of clinical workflows and facility specifics. Attracting the in-house medical professionals to an EHR implementation is a great way to make the solution more user-friendly. This way, clinicians also can learn how to use the system before its deployment. For the development team, such cooperation can help reduce the amount of post-development improvements, as clinicians can pinpoint some usability problems earlier in the development cycle when fixing bugs is easier.
   2. Create diverse testing teams. Naturally, clinicians’ computer literacy levels differ. However, each medical professional at a facility should be able to use the EHR solution freely. Therefore, it’s necessary to evaluate the staff’s computer competence and divide them into EHR testing teams, so that each team contains people of different levels of literacy. This way, users won’t only test the usability but also teach one another how to use the tool.

• Set up relevant EHR workflows. For this matter, attracting clinicians is also a viable idea. Computer-literate doctors (champions) can carefully map relevant EHR workflows, crossing out unnecessary steps or tasks and adding more relevant ones.

1. Conduct proper training. As we can see, many usability-related errors stem from the lack of knowledge of EHR functions, and targeted training can help bridge those gaps. The best way to train EHR users is by moving from simple EHR functions to more complex ones. This way, you can reduce cognitive overload in users with different levels of computer literacy.

It is also worth remembering that usability is not a static concept. EHR usability testing is required after major feature updates to make sure the addition didn’t disrupt user experience.

Summing up

EHR solutions are important tools that improve the quality of healthcare services. But at the same time, they can contain issues that may harm patients. To resolve them, you need to:

1. Evaluate usability by involving the staff who work with EHR.
2. Align the solution with the existing medical workflows.
3. Repeat usability testing after major updates to maintain the needed level of usability.
4. Ensure that users are well-informed about the solution’s functions via training sessions.

Retesting the solution’s usability after substantial functionality changes will help maintain its usability at the optimal level.