By the EHRA Clinician Experience Workgroup

EHR utilization places a number of burdens on clinicians that can impact decision-making, workflow and satisfaction. This has been confirmed by recent studies, including one published earlier this year by the Journal of Biomedical Informatics which found that clinicians face numerous cognitive demands when using EHRs. The study concluded that the management of those demands ultimately limits clinicians’ agency to work individually and collaboratively while failing to help them develop awareness of, or reason about, the big picture or their patients’ current and future states, including effects of potential treatments. 

A study in Journal of the American Medical Informatics Association (JAMIA) found that when goal-based decision-making, sense-making, and agency/autonomy are overlooked in EHR design, it results in increased cognitive load, emotional distress, and unfulfilling workplace environments. And a study from Mayo Clinic and the American Medical Association (AMA) and published in Mayo Clinical Proceedings, gave EHR usability a grade of F, which is “markedly lower” than for most other technologies. Researchers further noted a strong relationship between usability and risk for physician burnout.  

These usability challenges exist despite most EHR developers considering their customers and end users from the very start of development. In fact, 75% of the EHR vendors the EHRA surveyed about clinician usability indicated they interview their customers in advance of more than half of new product launches and regularly for existing software. Online surveys, prototypes and wireframes, focus groups, think-alouds and heuristic evaluation or expert reviews are just a few of the tools respondents indicated they use to seek out customer feedback.

These efforts are beginning to gain hard-fought recognition, too. In a study published in the May 2021 issue of the JAMIA, researchers reviewed usability practice descriptions provided by four EHR vendors. What was provided were descriptions of “user-centered design processes and usability testing methods that demonstrate advancement from previous studies of vendor practices.”

Another underappreciated truth is that while EHRs cannot be one-size-fits all, most are highly customizable by healthcare organizations and provider practices. As such, an EHR from the same developer will look and perform differently for a pediatric practice than it will for an orthopædic practice. 

Usability ratings are also impacted by availability of comprehensive initial and ongoing EHR training and support for individual users, which are vital if clinicians are to feel the EHR is a tool that serves them, rather than the other way around. This has been borne out by studies which show that clinicians who don’t take advantage of opportunities to personalize their workflows – often because they’re not quite clear on how to do it – are less likely to be satisfied with their EHR. 

It is also true that the investment of time and effort by clinicians in learning how to effectively use and make the EHR their own very quickly pays off. Despite that return on investment, in Improving the EHR Experience Through Personalization (Nov. 11, 2018) KLAS notes that 66% of providers have little to no personalization in place:

“If there were a yellow brick road that led to higher EHR satisfaction, that path would be EHR personalization. Personalization leads to better EHR efficiency, better physician agreement that the EHR enables quality care, more provider trust that the EHR vendor has built a quality tool, and higher overall EHR satisfaction. 

“EHR personalization can be divided into three overarching categories: data input, data output, and EHR workflows. Each personalization within these three categories has an immense impact on providers’ Net EHR Experience scores, and on average, providers who report high personalization have Net EHR Experience scores more than 30 points higher than those who don’t.

“Unfortunately, instead of investing their own resources into making providers aware of how personalization tools can improve usability and efficiency, many organizations are waiting on EHR vendors to make dramatic improvements to the EHR user interface. But if organizations want to see improvement, all they have to do is focus training and follow-up education on data input, data output, and EHR workflows.”

A blog post from the American Academy of Pediatrics provides several examples of personalization. For instance, “favorites” can be used to quickly find commonly used documentation:

“The specialty can set medications, imaging, referrals and other orders to reduce the catalog from which to choose…Favorites unique for the specialty can be further refined to meet an individual provider’s practice habits and patient population. A thoughtful reduction in choices can lead to more perceived freedom in the ordering catalog and a subsequent increase in EHR satisfaction.” 

U.S. regulatory demands are often onerous, mandating capture of not only notes but also data primarily related to quality measures, public health and other programs that goes beyond documentation for the immediate delivery and coordination of care. Thankfully, government agencies are working to pare them down. In the meantime, “Providers in the U.S. write notes that are three to four times longer than notes in other countries, in part because of older regulations that were made for a paper world. Health systems often have conservative interpretations of these regulations, so they encourage clinicians to duplicate information in the note that can easily be found elsewhere in the EHR,” Epic’s Dr. Jackie Gerhart told Healthcare IT News.

EHRs are not perfect, but everyone who uses them recognizes the benefits, and they continue to improve with every upgrade. No matter what individuals think of their EHRs, does anyone ever really want to go back to paper?