The Need to Optimize the Electronic Health Record: Usability Issues

in Legacy Systems Can Compromise Patient Safety

Rebecca A. Meehan

School of Information, Kent State University, 1125 Risman, Kent, OH, U.S.A.

Keywords: EHR, Usability, EHR Optimization.

Abstract: It is imperative that usability issues affecting patient safety continue to be fixed in the electronic health record

(EHR), especially in legacy systems that may not be updated or replaced for years to come. EHR developers

and vendors are partners with hospital systems and clinicians in identifying, prioritizing and fixing problems

in the EHR that may adversely affect patient safety. Many of these issues are identified by clinicians as issues

of poor usability. This presentation discusses current processes for identifying, prioritizing and fixing

usability issues as they arise in the implemented or legacy system by both vendors and hospital groups.

Strategies for how to improve processes moving forward are discussed.

1 INTRODUCTION

As we strive to improve health care by leveraging

advancements in health information technology, it is

imperative to fix usability issues affecting patient

safety in the electronic health record (EHR) both in

new system implementations and in existing legacy

systems. This addresses the recommendation by the

American Medical Association (AMA, 2014) when it

recommended strategies for improving care by

improving EHR usability. Among eight

recommendations, the AMA report calls for methods

to expedite user input into EHR design and to gather

post-implementation feedback. Usability fixes

recommended by end-users are part of the post-

implementation feedback but may be stymied by an

organizational culture or infrastructure that is not

prepared to offer feedback, or at least timely detailed

feedback. There can be propensity for organizations

to justify enduring with their existing EHR, despite

poor usability because of competing priorities, or

other flawed justifications such as the team can find

workarounds for the issue, or they should just wait

and the issue will be corrected in a new system.

However, the new system might be years away. And,

for usability issues that are impacting patient safety

outcomes, there is no time to wait.

This paper describes the foundational pieces to an

on-going research project examining the current

processes and strategies for improvement for

identifying, prioritizing, and fixing usability issues as

they arise in the implemented or legacy system by two

major stakeholder partners: EHR developers/

vendors and hospital groups. These issues can be

seen as part of EHR optimization, or the timing in the

EHR implementation cycle of making the EHR the

most effective, efficient, and supportive it can be.

(Romero & Staub, 2016). This includes identifying

processes and elements that have poor usability,

resulting in harm or the potential to harm patients.

The steps to examine the practices of how errors and

usability issues related to the EHR are resolved

include the following:

Step 1 How are issues identified: who reports the

issue and to whom (a supervisor, information

technology (IT) representative, EHR vendor

representative).

Step 2 How are issues prioritized: what is the process

for collecting the list of issues and assigning them

with high priority or low priority (committees, unit

supervisor, IT department, EHR vendor, CMIO).

Step 3 When these EHR usability problems

compromising patient safety are indeed fixed, how

long does it typically take and what is the process for

getting the fix implemented into the system, and

communicating the fix to stakeholders, especially the

original reporter.

These process components of addressing usability

issues in the built legacy EHR from the perspective of

both the EHR vendors and the hospital/ health

provider stakeholder groups are critical to improving

patient safety.

Meehan, R.

The Need to Optimize the Electronic Health Record: Usability Issues in Legacy Systems Can Compromise Patient Safety.

DOI: 10.5220/0009107106090613

In Proceedings of the 13th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2020) - Volume 5: HEALTHINF, pages 609-613

ISBN: 978-989-758-398-8; ISSN: 2184-4305

609

2 BACKGROUND

2.1 Rapid Adoption of the EHR

In the United States (US), the Health Information

Technology for Economic and Clinical Health

(HITECH) Act, as part of the American Reinvestment

and Recovery Act (2009) provided financial

incentives for eligible providers and hospitals to

adopt EHRs and use them meaningfully. As a result,

there was a rapid increase of EHR adoption from 9%

of all hospitals with a basic EHR in 2008 to over 96%

of all hospitals using a certified EHR in 2017

(https://dashboard.healthit.gov/quickstats/pages/FIG

-Hospital-EHR-Adoption.php). This rapid adoption

and implementation cycle have been criticized

(Schulte & Fry, 2019) for how it likely created risk

for EHRs to be implemented that met requirements,

but also had some usability issues that may result in

unintended consequences compromising patient

safety.

2.2 Benefits of the EHR

The EHR is used worldwide to maintain health

records, transforming the way clinicians and patients

interact with health information. The EHR

contributes to improved quality of health care through

improved visibility of data, allowing for a more

complete health record to be stored, accessed and

shared. The EHR has transformed healthcare in that

it enables clinicians to have more information about a

patient’s medical history, diagnosis, allergies,

medications, imaging and lab results, etc. in order to

inform the best care possible. Beyond these

advantages, the EHR also brings challenges and

unintended adverse consequences associated with

poor EHR usability.

2.3 What Is Usability?

Usability is defined as how useful, usable and

satisfying a system is for the intended users to

accomplish goals in their work (Zhang & Walji,

2011). In order for the EHR to have good usability,

the software should be intuitive, and easy to use so

that clinicians and other stakeholders to get their jobs

done, without the stress of not understanding how to

use the system. For clinicians, this means getting the

right information, for the right patient at the right

time, so that information about the patient’s health

history, medications and current status can inform the

best care possible. In today’s digital health

environment, so much more information can be

presented to the clinician in the care process (e.g.

medication information, imaging, social determinants

of health, allergies, prior health status, etc.). The

numerous data sources have the potential to provide a

more comprehensive view of a patient’s health.

However, poor usability can, not only jeopardize this

ability for the clinician, but it also can lead to patient

harm. For example, the clinician may choose to

prescribe a medication. These medications are often

presented in the EHR using a data field or drop-down

selection box. So, in this example, it is critical for the

drop-down box to show the full name and dosage

amount, and not have that view obscured or shortened

so that the wrong medication or dosage is selected

accidentally. Obviously, by selecting the wrong

dosage or medication, the patient could be harmed.

Not only are there compromises to patient safety, but

poor usability affects the clinicians who use them.

The EHR system needs to be easy to use, in order to

minimize the fatigue of end users, and to allay

clinician burnout (Gardner, et al, 2019). Poor

usability in the EHR, being used in the context of a

stressful health care setting has resulted in unintended

consequences compromising patient safety (Howe, et

al, 2018) and new unintended consequences (Sittig, et

al, 2016).

2.4 Unintended Consequences

Campbell and colleagues (2006) describe several

unintended adverse consequences of computerized

provider order entry (CPOE) systems a few of which

include more/new work for clinicians, changed

communication patterns, unfavourable workflow

issues, generation of new kinds of errors, unexpected

changes in power structure, and overdependence on

the technology. These issues continue to shape the

efficiency and effectiveness of the EHR by virtue of

the effect on the end users, both individually and as

part of organizational culture. As a result, work

patterns, expectations and satisfaction levels change.

Despite tremendous progress in EHRs, unintended

adverse consequences of the EHR have evolved over

the years. Sittig and colleagues (2016) described new

unintended adverse consequences of the EHR, some

of which include complete clinical information

unavailable at the point of care, inadvertent

disclosure of large amounts of patient-specific

information; a decline in the development and use of

internally-developed EHRs, and lack of innovations

to improve system usability leading to frustrating user

experiences. This evolution of unintended adverse

consequences is indicative of the exponential growth

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in the use of EHRs, as well as the tremendous

capability of the systems.

Substantial increases in the amount of time

required to interact with the EHR by clinicians and

other hospital staff is changing clinical care patterns

and interactions with patients. Clinicians are

reporting lower levels of job satisfaction and early

burnout (Gardner, et al, 2019). This experience can be

made worse by poor EHR usability, disrupting

workflow and creating workarounds. Staff burnout

continues to be an issue, and strategies to ameliorate

this call for technology solutions to be improved by

clinician-vendor collaboration in design and

deployment (The Lancet, editorial, 2019).

2.5 Legacy System

A legacy EHR system is one that has been

implemented and used by a hospital system or

provider office for over three years. A legacy system

is not brand new, but it is one that the organization is

living with or has lived with for quite a while. As

technology evolves, EHRs are delivered and

maintained on different technological platforms, each

with different ways in which they can offer updates

to health care provider and hospital clients. These

platforms include local on- site servers, software as a

service, and cloud-based systems. Regardless of

platform, fixes to the software can be delivered in a

few different ways. 1) Software fixes delivered as

“patches” are made available with the most frequency

and can offer a temporary fix to an error, until the

code is incorporated into the new upgrade base code.

2) Fixes to high priority issues to live systems that

need immediate attention can be delivered as

“hotfixes.” 3) A “system update” to the software

occurs with some regularity but can be less frequent

and tend to include several fixes or enhancements to

a system. The time it takes for a usability issue with

the EHR to be identified, prioritized and fixed will

vary widely. Because of this, communication back to

the original person reporting the usability issue can be

inefficient and ineffective.

2.6 Communication

Communicating the details of these fixes is important

so that the clinicians who originally called for the fix

can see that the change has been made. If there is too

much time that elapses between the original request

and the fix, the danger is that inefficient workarounds

will continue to be used. Moreover, it slows down

progress and improvements. Any type of fix to the

EHR software is typically communicated with some

form of release notes, so that when the client applies

the fixes, other stakeholders can read what changes

are being addressed in the fix. Mis-communication

issues can arise when the release notes are not readily

available, or if clinicians on site at the hospital or

health provider do not read the notes, and hence may

not be informed until they use the system and see that

it is running differently. This communication is

important so that clinicians can stop using

workarounds and start using the EHR as intended.

2.7 EHR Optimization in Legacy

Systems

EHR implementation has been the focus of efforts by

vendors, hospitals, consulting groups, and both

government-based and independent organizations for

health care quality over the past several years. Now

that, as of 2017, 96% of hospitals in the US have

implemented certified EHRs

(https://dashboard.healthit.gov/quickstats/pages/FIG

-Hospital-EHR-Adoption.php, accessed 11-9-19),

stakeholders have an opportunity to make these

systems more effective and efficient as part of an

EHR optimization phase (see Figure 1).

Figure 1: Cycle of EHR Implementation and Optimization.

EHR optimization is the process that takes place

after implementation to maximize the benefits and

utility of the system (Moon, et al, 2018). Others have

described EHR optimization as ongoing, and

necessary to be incorporated into each organization’s

structure and culture (Blavin, et al, 2013). In a like

manner, system maintenance is continuing, and can

facilitate optimization. Overall, it is in the phase of

EHR optimization that usability issues compromising

patient safety can be identified, prioritized and fixed.

This ongoing vigilance about how the system should

be working is critical. To that end, it is important to

identify best practices to support optimization and to

make improvements in care and patient safety

outcomes.

Determining

EHR

EHR System

Selection

Implementation

Maintenance

Optimization

The Need to Optimize the Electronic Health Record: Usability Issues in Legacy Systems Can Compromise Patient Safety

611

3 CURRENT STRATEGIES

When hospital end users encounter a problem with

the usability of the EHR, leading to potential for

patient safety concerns, they need to have an

organized way of getting it fixed. Part of this can be

addressed by voluntarily completing a patient safety

report on site in the hospital to give others visibility

to the issue. Another part of the process involves

taking necessary steps to bring the issue to the

attention of the EHR developer/ vendor. This process

not only requires an efficient and effective process on

the health care provider/ hospital side, but also with

their EHR vendor/ developers. A partnership

between the hospital and the vendor is a necessity in

order to facilitate post-implementation feedback and

to optimize the EHR by fixing the system to avoid

errors that may compromise patient safety.

3.1 EHR Developers/ Vendors

There is little to no literature on the best practices of

EHR optimization from the EHR developer/ vendor

stakeholder group. Still, developers and vendors have

processes in place for continuous improvement

including the timely fixes made as the EHR product

is supported and given new modifications under

standard maintenance. Fixes to the system or

improvements to the system are typically driven by

product enhancements or additional functionality that

did not make it into the first release of the product,

but, instead were planned as part of future releases, in

which clients would be able to take an upgrade to their

system for these new pieces of functionality.

Changes by the developer/ vendor to the EHR are also

driven by enhancement requests and fixes/ tickets

requested by the hospital / health provider client.

These requests need to be prioritized and decisions

need to be made on if and when they will be fixed for

the client’s EHR system. Moreover, decisions are

made on how the clients will be able to take and apply

these fixes to their system: will it be a patch made

available immediately for one client or more clients,

part of a routine update to the software, made

available at the next release, or will these changes be

incorporated into a new product release altogether,

and available for an additional cost to existing

clients? These decisions about priorities are typically

made by the product team and may not be uniformly

applied. Many usability related requests often make

it onto the product backlog, waiting for a time to be

incorporated into the system. And many of these

backlog issues have a hard time seeing the light of

day. Many EHR vendors/ developers have talked

about struggles with moving items from the backlog

and into the current sprint (for an agile development

process) and into the product.

Inevitably, product teams and usability experts

need to advocate for these usability changes to be

made to the existing system. This can be difficult to

prioritize these fixes over delivering new

functionality or working around ever changing

regulatory requirements for the EHR. This is a

continuing cycle, and one that needs attention in order

to understand best practices. In a like manner,

hospitals/ providers need to have an efficient and

effective way of fixing usability problems in legacy

EHR systems.

3.2 Hospitals/ Clinical Provider

Hospital systems need to find efficient processes to

identify these usability issues that need to be fixed

within the EHR, because organizations typically “live

with” these systems between 7-10 years before new

and updated systems are implemented. There are

occasional updates to the EHR, but those are typically

made on individual components and are not

comprehensive. These processes are part of EHR

optimization, the continuous process of assessing the

system for ways to improve efficiency (Romero &

Staub, 2016).

There is a limited literature on work done in this

area, however, Moon and colleagues (2018) used a

qualitative approach to conduct interviews and focus

groups with high performing health care

organizations in the US. Results from their study

describe relevant issues that arise during the

optimization process, including the exponential

uptick in software enhancement or change requests

after the product go-live. There was no associated

process of efficiently addressing these concerns.

Recommendations from the study include that

hospitals/ health providers should dedicate resources

to addressing optimization issues going forward.

4 STRATEGIES FOR MOVING

FORWARD

4.1 Partnership between Vendors and

Clinical Providers

Moving forward, the way to optimize the EHR to

protect patient safety outcomes stemming from

usability fixes may be to rely on a partnership

between EHR vendors / developers and clinical or

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hospital providers. Both stakeholder groups play a

role in the organization of a strategy and commitment

to the continuing process of identifying, prioritizing,

fixing and communicating fixes on the EHR back to

all stakeholders.

4.2 Future Research

In order to evaluate the current status and practices

for identifying, prioritizing and fixing patient safety

issues related to poor usability in legacy EHR

systems, Kent State University (USA), led by the

author, is conducting survey research among both

EHR vendors and hospital systems in the United

States. Key metrics include:

● descriptors of the size and type of hospital or EHR

vendor;

● number of patient safety related fixes to the EHR

reported vs. number of fixes made;

● descriptors of platform types of EHR products

used or made (e.g. cloud based, local install);

● identification of where fixes are made (on-site at

the hospital IT department or at the EHR vendor

site);

● description of current process to identify,

prioritize and fix patient safety issues related to

usability;

● description of what in the current process is

working well and what needs to be improved.

This study will be divided into two phases, one for

each stakeholder group: 1) EHR developers and

vendors, and 2) hospitals/ clinical providers. Data

collection is ongoing. Implications for patient safety

outcomes related to EHR optimization processes will

be discussed.

REFERENCES

American Medical Association. (2014). Improving care:

priorities to improve electronic health record usability.

Available at: https://www.aace.com/files/ ehr-

priorities.pdf.

Blavin F., Ramos, C. Shah, A., & Devers, K. (2013).

Lessons from the literature on electronic health record

implementation: a study funded by the Office of the

National Coordinator for Health Information

Technology of the US. In: Department of Health and

Human Subjects.

Campbell, E. M., Sittig, D. F., Ash, J. S., Guappone, K. P.,

& Dykstra, R. H. (2006). Types of unintended

consequences related to computerized provider order

entry. Journal of the American Medical Informatics

Association, 13(5),547–556.

Doi:10.1197/jamia.M2042

Gardner, R. L., Cooper, E., Haskell, J., Harris, D. A.,

Poplau, S., Kroth, P. J., & Linzer, M. (2018). Physician

stress and burnout: the impact of health information

technology. Journal of the American Medical

Informatics Association, 26(2), 106-114.

Howe, J. L., Adams, K. T., Hettinger, A. Z., & Ratwani, R.

M. (2018). Electronic health record usability issues and

potential contribution to patient harm. Journal of the

American Medical Association, 319(12), 1276-1278.

Moon, M. C., Hills, R., & Demiris, G. (2018).

Understanding optimisation processes of electronic

health records (EHRs) in select leading hospitals: a

qualitative study. British Medical Journal Health &

Care Informatics, 25(2), 109-125.

Non-federal Acute Care Hospital Electronic Health Record

Adoption. (n.d.). Retrieved from https://dashboard.

healthit.gov/quickstats/pages/FIG-Hospital-EHR-

Adoption.php

Romero, M. R., & Staub, A. (2016). Specialty task force: a

strategic component to electronic health record (EHR)

optimization. Nursing Informatics, 225,1051-1052.

Doi: https://doi.org/10.3233/978-1-61499-658-3-1051.

Schulte, R., & Fry, E. (2019). Death by 1,000 clicks: Where

electronic health records went wrong. Kaiser Health

News, 18.

Sittig, D. F., Wright, A., Ash, J., & Singh, H. (2016). New

unintended adverse consequences of electronic health

records. Yearbook of medical informatics, 25(1), 7-12.

The Lancet, editorial (2019). Physician burnout: the need to

rehumanise health systems. Lancet, 394(10209), 1591.

Doi: https://doi.org/10.1016/S0140-6736(19)32669-8

Zhang, J., & Walji, M. F. (2011). TURF: toward a unified

framework of EHR usability. Journal of Biomedical

Informatics, 44(6), 1056-1067.

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