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3 Strategies to Enhance EHR Usability Through EHR Optimization

Being able to adapt and optimize new EHR technology is crucial to the future of EHR usability.

It is common to put an emphasis on the EHR vendor and implementation of new EHR technology. However, sustaining the technology and enhancing EHR usability comes down to EHR optimization.

Better EHR usability leads to higher EHR adoption rates, fewer clinical errors, less clinician burnout, financial benefits, and improved patient safety.

Per HIMSS, EHR usability is defined as “The effectiveness, efficiency and satisfaction with which specific users can achieve a specific set of tasks in a particular environment. In essence, a system with good usability is easy to use and effective. It is intuitive, forgiving of mistakes and allows one to perform necessary tasks quickly, efficiently and with a minimum of mental effort.”

But according to a study completed in a partnership between the Mayo Clinic and the American Medical Association (AMA), EHR usability leaves a lot to be desired. Researchers found that EHR usability was graded an “F” when evaluated on a letter grade scale by most providers.

“While the study was conducted by leading clinical institutions in collaboration with the American Medical Association (AMA), the findings will not come as a surprise to anyone who practices medicine,” said Patrice Harris, AMA president. “Too many physicians have experienced the demoralizing effects of cumbersome EHRs that interfere with providing first-rate medical care to patients.”

EHR optimization goes hand in hand with maintaining and improving EHR usability, pushing main usability issues to the forefront.

“Oftentimes when people think about usability, they think about design and then they think about the EHR vendor,” Raj Ratwani, PhD, director of MedStar Health Human Factors Center, said in an interview with EHRIntelligence.

“In reality, it's a very complex space. The products that are being used by frontline clinicians are shaped by the vendor. But they are also shaped by how that product is implemented at that provider site, how it's customized, and how it’s configured.”

As more health organizations work to optimize their EHRs, they should look at the current status of their EHR usability, assess interface usability, and invest in EHR user training.

Maintaining EHR usability through testing and optimization

Keeping an EHR maintained and up to date is crucial for usability. However, the EHR reporting program, which is currently being developed by the National Coordinator for Health Information Technology (ONC), has yet to be unveiled.

Until that program launches, health systems will have to conduct internal tests to maintain EHR usability throughout the life of its EHR system.

First, health organizations need to accept feedback from its EHR users.

Gaining feedback from clinicians is a key factor to sustaining EHR usability and optimization. But according to a 2018 Deloitte survey, 66 percent of physicians were not asked to provide feedback in regards to EHR optimization decisions.

This is something that needs to change, experts say.

Once the EHR system is implemented, healthcare organizations can execute summative testing. These tests include expert review, performance testing, risk assessment, and usability testing.

Together, these activities can help healthcare providers evaluate EHR efficiency, effectiveness, cognitive load, and optimization.

A way to assess satisfaction is the system usability scale (SUS).

The SUS scoring system is used by most EHR vendors. It is a validated post-test questionnaire that measures user satisfaction with product ability.

The system is based on a 100-point scale using respondent answers to a 10-question survey regarding the EHR product’s usability. The higher the score, the better the usability. According to researchers, a 68 is an average benchmark response and an 80 is above average.

This provides feedback to the vendor to enhance design and health systems may also take the results of the test to enhance optimization.

Until the EHR reporting program is deployed by the ONC, health systems have to govern EHR usability through those imperfect usability assessments.

Optimizing the EHR interface to enhance EHR usability

Ultimately, looking at the user interface for the EHR is going to have the biggest impact on optimization. Interface navigation directly affects how providers use the tool in their everyday practice, having a downstream impact on patient safety, clinic operations, and burnout.

A cluttered interface or a complex medication list is the result of an EHR product that is not properly designed or optimized. Seeing a cluttered list of medication leads to potentially deadly consequences.

Lack of data integrity, too, can be an issue. In a recent Pew report, researchers outlined an EHR usability issue regarding the collection of weight data and how it impacted medication prescribing.

“In one case, a clinician entered a child’s weight in pounds when the EHR was configured for kilograms,” explained Ben Moscovitch, project director for Health Information Technology at Pew. “The misunderstanding effectively doubled the child’s actual weight, resulting in the patient later receiving twice the appropriate drug dose.”

Making sure the EHR is properly set on the correct drug entry measurement could be the difference between life and death. If a decimal point is off, or the user was not properly trained on the measurement, serious consequences could arise.  

This is an extreme, yet actual example of an EHR usability issue, a key challenge that could be fixed with an optimized EHR interface.

In a separate effort to optimize and clean up the EHR interface, researchers from Beth Israel Deaconess Medical Center implemented a simple visual aid in the EHR to address repetitious or unnecessary test ordering.

Instead of an interruptive alert, researchers set up an EHR visual aid that placed a simple red highlight around the checkbox of the laboratory test order, alerting the clinician to a duplicative or incorrect test order.

Following this implementation, researchers found a 49 percent decrease in unintentional duplicate orders for laboratory tests and a 40 percent decrease in unintentional duplicate orders for radiology tests.

“In our EHR, it takes a minimum of 9 clicks and password entry to cancel an order,” researchers wrote. “Estimating the burden of order cancellation at 9 clicks and 30 seconds, the estimated reduction in unintended duplicate orders saved 17 936 clicks (not including the password) in the year after the intervention, which amounts to 16 hours and 36 minutes of regained productivity.”

“This type of EHR-based reminder may be a useful alternative to interruptive, post-order alerts for reducing duplicate order entry,” continued the researchers. “We believe guiding clinicians to a right action is better than telling the clinician they have made an error. This approach may help reduce alert fatigue and lessen clinician stress and burnout associated with EHRs.”

Although these alerts were set up for laboratory test orders, a similar alert could be implemented into the EHR to remind clinicians of the measurements used for particular drug dosing.

With EHRs constantly updating their interface, the ability to adapt to these changes is crucial.

Poor EHR training has a great impact on EHR usability and optimization

According to a 2019 survey by the KLAS Arch Collaborative, health systems deploying adequate EHR training to clinicians is vital to EHR usability and provider satisfaction.

As stated above, EHRs are constantly updating after implementation. Keeping up with the updates from a technology standpoint is one thing but making sure the EHR user can successfully adapt to the changes is another.

Researchers surveyed EHR usability data from the Arch Collaborative to identify satisfaction factors.

“We as an industry have an opportunity to improve EHR adoption by investing in EHR learning and personalization support for caregivers,” wrote researchers.

“If health care organizations offered higher-quality educational opportunities for their care providers — and if providers were expected to develop greater mastery of EHR functionality — many of the current EHR challenges would be ameliorated,” they continued.

Different users of the same software experienced different results, largely as a result of EHR training, the researchers observed. This is a clear EHR training issue.

Researchers found 475 cases in which two physicians in the same specialty used the same EHR system. However, the users did not have the same experience.

“In over 89 percent of these instances, the physician who strongly agreed also reported better training, more training efforts, or more effort expended in setting up EHR personalization,” said researchers.

Investing in training allows users to properly navigate the EHR interface, rather than implementing a new EHR.

“In the Arch Collaborative large dataset, the single greatest predictor of user experience is not which EHR a provider uses nor what percent of an organization's operating budget is spent on information technology, but how users rate the quality of the EHR-specific training they received,” researchers wrote.

EHRs have become a ubiquitous health technology impacting the experiences of clinicians and their patients across the country. But although most provider organizations have an EHR, it does not mean the process is perfect.

As organizations work to perfect their EHR technologies, they may consider different strategies to assess usability, identify key interface changes that improve provider workflow, and implement strong user training.

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