Enhanced EHR Usability Starts With Understanding Users’ Needs and Challenges

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?

State of the Note Summit 2021 from ACP and EHRA

By EHRA Clinician Experience Workgroup

In January of this year, CMS adopted new billing guidelines from the American Medical Association (AMA) regarding E&M coding. The new guidelines include a wide variety of much-needed changes focused on streamlining billing processes and reducing clinical documentation burdens.

Seeing this as a watershed moment for clinical documentation and an opportunity to produce shorter, more clinically focused notes, the American College of Physicians (ACP) partnered with the Electronic Health Record (EHR) Association. Together, we examined the practical impacts of the coding changes with our community of vendors and clinical stakeholders, specifically:

  1. What consensus about documentation burden exists across vendors, healthcare organizations, and specialist societies when interpreting the guidelines?
  2. What questions, if any, exist around the guidelines?
  3. How can we effectively educate the community about the impact of the guidelines?

The USCDI Curation Process: Why Stratify?

By John Travis and members of the EHRA Information Blocking Task Force 

In our last blog on the United States Core Data for Interoperability (USCDI), the focus was on USCDI as the policy ground for advancing federal interests for promoting high impact needs for health data, and USCDI’s import as a certification specification impacting developers of Certified Health Information Technology (CHIT). In this blog, we focus on how the evolution and curation of USCDI impacts the efforts of health IT developers and implementers to “stay current.” 


The Balance Challenge for Policy in Progressing the U.S. Core Data for Interoperability (USCDI)

By John Travis and members of the EHRA Information Blocking Task Force


With publication of the 21st Century Cures Act: Interoperability, Information Blocking , and ONC’s Certified Health IT program final rule (Cures Act Final Rule), the Office of the National Coordinator for Health IT (ONC) worked to implement important provisions of the 21st Century Cures Act (Cures Act) for nationwide interoperability. The initial proposal from ONC addressing the Trusted Exchange Framework and Cooperative Agreement (TEFCA), which was also required by the Cures Act, created a central role for the U.S. Core Data for Interoperability (USCDI) in federal health IT policy, and it is important to consider what that role will be in the national policy framework. Will the USCDI push the industry beyond where it would go on its own by being progressive in its version expansion? Will it affirm and codify an extension of the current state, adhering to a principle of expansion based on supporting pre-requisites of already established interoperability standards? Or something in between?

In recent deliberations of the USCDI Task Force of the Health Information Technology Advisory Committee (HITAC), the Federal Advisory Committee established under the Cures Act, this tension point has come to light. The members of the task force seem to have two perspectives on the matter. 


Five Ways EHRs Are Helping CDC Track COVID-19 Vaccinations

By the EHR Association COVID-19 Task Force

In December, two COVID-19 vaccines received authorization from the FDA, and the federal government began distribution to the states almost immediately. Millions of Americans have already received their first dose – many their second – and millions more will be vaccinated in the coming weeks and months. While social distancing, frequent hand washing, and face masks remain vital tools in limiting spread of coronavirus, we can increasingly see our way to a full return to hugs and handshakes, in-person meetings, travel, pubs and parties, concerts and classrooms.

As we anxiously await a return to our old way of life, public health experts, policymakers, and the public are watching the CDC vaccine data tracker, updated every evening with the latest numbers, including: 

  • How many vaccine doses have been distributed to-date? 
  • How many vaccines have been administered?
  • How many people have received their first dose? 
  • How many people have gotten a second dose?
  • Which vaccine is being administered?

But how does the CDC get all that data? The answer varies, but it’s made possible by technology, and electronic health records (EHRs) have been a key player from the beginning. 

Here are five ways that EHRs and the EHR Association are playing important roles in vaccine administration and data collection in the United States.


Securing API-based Access to Patient Data

By EHRA Standards & Interoperability Workgroup

One of the goals of the 21st Century Cures Act’s health IT provisions was to enable patients to have secure access to their electronic health information using Application Programming Interfaces (APIs). The Office of the National Coordinator for Health IT (ONC) advanced that objective when it published its May 2020 Final Rule, which specifies HL7(R) FHIR(R)-based standards that health IT developers (as well as provider organizations developing their own solutions) will be expected to implement so that patient can access their health data using apps of their choice, connected to APIs. But how can patients be assured that their health information is secure once it leaves the EHR? 

Health data are among an individual’s most sensitive information, obligating all members of the healthcare community to protect patient privacy by ensuring secure data exchange. This blog post will review how the ONC standards for patient access can enable best practices to securely share patient health data.

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