July/August 2021

EHRs, Usability Remain at Odds
By Elizabeth S. Goar
For The Record
Vol. 33 No. 4 P. 16

Industry insiders share their thoughts on a new study spotlighting the technology’s long-standing shortcomings.

Given the complexity involved with achieving a proficient EHR and adopting the inevitable workflow changes, the findings of a recent study that perceptions about usability improve only slightly within the first year following go-live should come as no surprise. What might be surprising, however, is just how little that changes even two years post adoption.

“Learning new systems in your work settings can be hard, but eventually most people believe that the work will get easier over time. In our case, we found that after 2.5 years of using the new system, the workload remained two to three times higher than the prior EHR,” says Karen Dunn Lopez, PhD, MPH, RN, director of the Center for Nursing Classification & Clinical Effectiveness at The University of Iowa College of Nursing. “Clinicians’ perceptions of usability improved after six to eight months but remained significantly lower than the baseline measure.”

Documenting Persistent Problems
Dunn Lopez and her colleagues spent 2.5 years studying the usability and workload associated with EHR use before and after the switch to a large vendor system—one of the longest studies of its kind. Published in the February 2021 issue of Applied Ergonomics, “Electronic Health Record Usability and Workload Changes Over Time for Provider and Nursing Staff Following Transition to New EHR” found that poor usability and workload associated with EHRs continued to be a significant concern among clinicians, with issues persisting for 30 months for both physicians and nurses.

And while usability ratings were moving closer to preimplementation levels at the 30-month mark—suggesting that EHR usability may have recovered over a longer period—it nonetheless reflects a significant duration of time during which usability was reduced.

“I was most surprised about the length of time that ... the systems were perceived to have poor usability and high workload,” Dunn Lopez says.

EHR workload more than doubled six months following the system switch and remained at about that level for the full 30 months. The only exception was in the “physical activity" subscale, “suggesting EHR adoption primarily increased cognitive workload, presumably in part because the EHR was now used to deliver patient care during visits rather than to document care after these visits.”

The researchers further suggest that design flaws—even small ones—add up when using an EHR several hours a day. For example, problems visualizing system status can impair user awareness of which step in a multistep process they are, or whether the system is processing a command or is ready for the next one.

Industry Reaction
Stephanie Murray, senior director of CereCore, Epic Services, was not surprised by the findings, but cautioned against applying them too broadly. The study focused on two Midwest ambulatory urgent care centers within the same health care system that transitioned to the same full EHR from the same hybrid model—the system was rarely used while seeing patients and was essentially an information repository.

“Given this context, this study would not equate to a study that compares cognitive workload when transitioning from one full EHR to another,” Murray says. “Additionally, key variables such as what type of system the users were trained on while in school—paper vs electronic—were not outlined in the article but could also play a factor in cognitive workload.”

Murray adds that a clinician’s perceptions about and experiences with EHR usability are complex and will vary based on a wide range of factors. Among these are their roles, responsibilities, system access, the number of systems being used, how well their various systems integrate, how well their workflow is emulated within the system, system lag, “and a thousand other things the brain processes subconsciously in an instant. Usability is a multifaceted and ever-moving target. What one person may find useful and ideal may be another person’s workflow nightmare,” she explains.

Christopher Maiona, MD, SFHM, chief medical officer at PatientKeeper, was particularly unsurprised by the correlation between lack of usability and increased workloads. The findings, he says, “reflect the reality that most EHR systems were not originally designed with clinicians in mind. They were designed to automate hospital operations and administrative functions, so clinicians generally have been forced to adapt their workflow to the requirements and structures of the EHR rather than the system supporting their clinical thought process and workflow.”

Maiona says that while most physicians he knows who work in acute care settings appreciate that EHRs are worthwhile, they also feel the system itself is cumbersome to use, costs time, and distracts from patient care. He notes that usability is about where, when, and how clinicians can access and interact with an EHR. Users want that to be anywhere, anytime, and with the fewest clicks, taps, or swipes possible.

User interface redesign and integration of artificial intelligence capabilities can go a long way toward improving clinician interactions with HIT systems—and how those systems contribute to patient care.

“Bottom line,” Maiona says, “systems should support clinicians’ workflow rather than disrupt that workflow or force users to adapt to the technology, which is the case all too often in hospitals and practices today.”

Wellsheet CEO and Founder Craig Limoli points out that the study makes a strong case that the frustration and dissatisfaction clinicians have with EHRs are largely driven by design failures. However, the recommendations for addressing those failures—training providers to better report usability issues—was a surprise.

The researchers note that informal discussions with clinical leaders suggest that the volume of change requests might lengthen the time-to-market for modifications. They suggest that better usability testing with real end users before implementation would decrease requests, and that clinicians should have formal education to help identify, report, and articulate usability problems.

While placing “the lion’s share of responsibility on the EHR vendors whose product may cost individual health systems upward of $1 billion … and indirectly on government agencies [that] can set incentives to improve EHR usability,” the study went on to recommend that provider organizations have strong and transparent governance processes to prioritize change requests and vet them for unintended consequences.

“Training providers to better report usability issues won’t help if EHR vendors continue to be so unresponsive to users’ needs,” Limoli says, adding that the study also fails to mention “tools that connect to the EHR that can radically improve the clinician experience much more quickly and easily than by modifying the underlying EHR.

“Clinicians understand the EHR was not designed for them, and that this creates immense frustration that leads to burnout. This [study] sheds light on how that perception is often most intense immediately after the implementation of the EHR, but it continues to be one of the biggest drivers of clinician burnout even in the long term,” Limoli continues, noting that some of those frustrations stem from the knowledge that there is little they can do to facilitate improvements.

“Clinicians are desperate for better systems they can use to manage patient information and deliver care efficiently and effectively,” Limoli says, and, while health systems make significant investments into optimizing their EHR systems, this “can be a huge burden on both clinical and technical staff.”

For Douglas Herr, vice president of EHR services with DeliverHealth, another unexpected omission was the study’s oversight of several EHR benefits—accuracy of notes, availability of patient information, greater patient access, and improved revenue capture—as motivators for clinical adoption.

“While I do agree with some of the findings, including the importance of user-centered design of the system workflows, the primary goal of transformation planning is to gain early adoption and buy-in by your end users,” he says. “Organizations must help the end user—in this case clinicians—gain a clear understanding of the benefits, even when they aren’t directly impacted.”

Integrity Factor
In the real world, EHR usability and cognitive workload affect more than the clinical workflow. They can also impact data integrity, which will complicate patient identification, information completeness and accuracy, and coding compliance.

Murray notes that when a system is designed to accommodate user actions, information can be entered without inhibiting workflows. However, “if a system forces users to think more about which button to click in order to satisfy compliance needs instead of caring for the patient, it distracts the user and interrupts patient care,” she says.

For example, actions such as documentation, dropping charges, and patient timestamps should not require “additional clicks or thought processing,” notes Murray, who says these measures should be built into the workflow naturally, and user interactions with the system should add value to the patient and the chart.

“When value is added, it should also result in more intrinsic motivation to comply with documenting these required elements,” she says. “When activities are logged ‘behind the scenes’ in ways that support recording the cascading steps that have occurred—instead of requiring clinicians to add clicks to their workflow—clinicians spend less time thinking about how to use the system and more time thinking about patient care.”

Julie A. Pursley, MSHI, RHIA, CHDA, FAHIMA, AHIMA’s director of health information thought leadership, points out that as focus shifts to whole-person care where data are captured and shared bidirectionally, it becomes necessary to prioritize new workflows and governance to address physician burnout. For that reason, optimizing EHR technologies to enable the capture, use, storage, and retention of quality documentation has been an important lesson learned over the years.

“Working cross-functionally with health information professionals, EHR teams, care providers, and other key stakeholders should be an iterative process to identify opportunities to enhance the workflow and lessen the cognitive workload,” Pursley says.

Failure to do so could spell disaster, because while data integrity is the floor to accurately identifying and matching patients to their unique health record, “it also can adversely affect the availability and reliability downstream,” Pursley says. “The cognitive workload may be worsened by data quality issues upstream.”

Change Has Happened
Other lessons have also been put into action regarding EHR usability, most of which have come from third-party innovation in conjunction with the EHR, according to Limoli.

While most innovation has been in the realm of revenue cycle management, “the APIs that enable solutions to integrate into EHR systems and provide value to clinician users in care delivery have advanced very meaningfully in the past several years,” Limoli says. This has, in turn, paved the way for technologies that can be added on to the EHR to significantly improve usability.

Maiona highlights the improvement seen in reducing the number of clicks required to accomplish certain tasks but notes that nearly all EHR systems still fall short of enabling clinicians to work on mobile devices while providing a personalized experience. Meaningful mobility, he says, requires a true native app, with a user experience analogous to what is experienced off the clock.

“A kludgy web connection that places you into the same desktop interface you see from your computer doesn’t cut it,” Maiona says.

As for personalization, he says that early EHRs displayed the same patient information regardless of area of practice, the patient’s disease state, or whether the patient was new or existing. It was also likely that the record was far from complete, missing everything from images to real-time vitals and progress notes. This made it difficult to find data, respond to test or lab results, delayed orders, and ultimately fractured a provider’s train of thought.

“As we look ahead to the next generation of health IT, a well-optimized EHR will take the existing data and present them in a way that is consistent with a physician’s thought process and workflow, enabling him or her to act on information quickly and accurately,” Maiona says.

“Physicians will interact directly with a ‘system of engagement,’ one that’s specifically designed to offer an instinctive user experience,” he continues. “What’s more, as the platform learns more about the physician workflow and more data are inputted into the system, physicians will be presented with more accurate alerts and prompts, streamlining EHR usage while improving the patient and physician experience.”

At a more basic level, Murray notes that accessibility considerations in user interface design have trended away from the use of color as an indicator to accommodate those who have difficulty distinguishing differences in color or are not inclined to use color as a differentiating factor. Another trend has been the adoption of additional icons to communicate status, next steps, and notifications, and to show as much on one screen as possible to reduce the amount of navigation required.

“This, however, has sometimes led to a very cluttered and overwhelming screen, which in turn decreases efficiency because it takes the clinician more time to find what they need,” Murray says. “As EHRs become more complex and offer a wider variety of configuration options, it will be important to try to avoid overengineering. After all, the patient should be the focus and facilitating their care should be the goal of the system.”

Opportunities for Improvement
As the usability study demonstrates, EHRs are far from overcoming the limitations that have plagued them from the start. It is a continuous—and urgent—process.

According to Robyn Stambaugh, MS, RHIA, practice director of professional development and education at AHIMA, if EHR inefficiencies are not identified and corrected quickly, they can exacerbate poor system perception and have the potential to impact long-term user experience.

“Additional unwanted outcomes from usability issues can be seen in a decrease in optimal use of a critical system vital to the patient care experience. And the organization’s return on investment in the system may not be actualized,” she says. “EHR design flaws can cause an exacerbation of stress and frustration for clinicians, along with an increase in clinical workloads.”

However, organizations can address some of these issues by establishing governance structures that support patient safety and the overall integrity of its health information. This establishes tenets to ensure the effective and efficient use of the EHR, Stambaugh says.

“To improve existing systems, stakeholders must establish a mechanism to prioritize known usability issues. Resolution of those issues must come from collaboration with their respective vendors to determine a timeline and best practices for mitigating identified issues,” Stambaugh says. “Engagement of health care stakeholders is critical for successful EHR implementation, now and in the future.”

According to Herr, the real opportunity for improvement—as well as for workflow advances and utilization gains—is to further align clinician and patient interests. Key to this will be maintaining clinical involvement in system designs, standardization of processes and change control, and workflow enhancement.

“No doubt, health facilities will continue to invest in areas such as advanced functionality of EHR portals, introduction to mobile technology, interoperability, home tracking devises, and much more,” Herr says. “These can all improve clinical adoption of technology and patient involvement in their own health management, creating a win-win scenario between doctor and patient.”

For Dunn Lopez, the study’s findings are “a call to fundamentally change the way EHR systems are designed to be easier to use. Health care is too important. We can’t have systems that cause safety problems or have such high workloads that talented clinicians burn out.”

She says vendors must conduct more rigorous systematic, user-centered testing. Other recommendations include requiring public usability metrics similar to the National Highway Traffic Safety Administration’s vehicle safety ratings, and forcing vendors to compete for business based on usability.

“Finally, I hope that physicians, other clinician EHR users, and policy makers use our study to spur changes for improved usability of EHRs,” Dunn Lopez says.

— Elizabeth S. Goar is a freelance writer based in Wisconsin.