Electronic Health Record Usability Research Articles

Implementation of a scalable, web-based, automated clinical decision support risk-prediction tool for chronic kidney disease using C-CDA and application programming interfaces.

Background and ObjectiveClinical decision support tools for risk prediction are readily available, but typically require workflow interruptions and manual data entry so are rarely used. Due to new data interoperability standards for electronic health records (EHRs), other options are available. As a clinical case study, we sought to build a scalable, web-based system that would automate calculation of kidney failure risk and display clinical decision support to users in primary care practices.Materials and MethodsWe developed a single-page application, web server, database, and application programming interface to calculate and display kidney failure risk. Data were extracted from the EHR using the Consolidated Clinical Document Architecture interoperability standard for Continuity of Care Documents (CCDs). EHR users were presented with a noninterruptive alert on the patient’s summary screen and a hyperlink to details and recommendations provided through a web application. Clinic schedules and CCDs were retrieved using existing application programming interfaces to the EHR, and we provided a clinical decision support hyperlink to the EHR as a service.ResultsWe debugged a series of terminology and technical issues. The application was validated with data from 255 patients and subsequently deployed to 10 primary care clinics where, over the course of 1 year, 569 533 CCD documents were processed.ConclusionsWe validated the use of interoperable documents and open-source components to develop a low-cost tool for automated clinical decision support. Since Consolidated Clinical Document Architecture–based data extraction extends to any certified EHR, this demonstrates a successful modular approach to clinical decision support.

Improving the safety of health information technology requires shared responsibility: It is time we all step up

In 2011, an Institute of Medicine report on health information technology (IT) and patient safety highlighted that building health-IT for safer use is a shared responsibility between key stakeholders including: “vendors, care providers, healthcare organizations, health-IT departments, and public and private agencies”. Use of electronic health records (EHRs) involves all these stakeholders, but they often have conflicting priorities and requirements. Since 2011, the concept of shared responsibility has gained little traction and EHR developers and users continue to attribute the substantial, long list of problems to each other. In this article, we discuss how these key stakeholders have complementary roles in improving EHR safety and must share responsibility to improve the current state of EHR use. We use real-world safety examples and outline a comprehensive shared responsibility approach to help guide development of future rules, regulations, and standards for EHR usability, interoperability and security as outlined in the 21st Century Cures Act. This approach clearly defines the responsibilities of each party and helps create appropriate measures for success. National and international policymakers must facilitate the local organizational and socio-political climate to stimulate the adoption of shared responsibility principles. When all major stakeholders are sharing responsibility, we will be more likely to usher in a new age of progress and innovation related to health IT.

Reflective Technology Assimilation: Facilitating Electronic Health Record Assimilation in Small Physician Practices

Effectively incorporating complex technology into organizational practices requires moving beyond initial plateaus of postadoption usage. However, achieving this is especially challenging for small businesses because competing priorities in addition to resource and attention constraints may lead to technology assimilation satisficing. With this context in mind, we conducted a four-year action research project in which we supported electronic health record (EHR) assimilation in 10 small physician practices by facilitating reflections to help these small organizations move beyond an initial plateau of postadoption EHR usage. Drawing from these results, we theorize reflective technology assimilation (RTA) as an emergent process of facilitating deeper learning and reflection within and across small resource- and attention-constrained organizations to enable ongoing technology assimilation. In addition, we articulate the foundational principles for reflective action research (RAR) as an approach in which researchers facilitate reflective problem solving while advancing theoretical knowledge.

Use of EHR-based simulation to diagnose aetiology of information gathering issues in struggling learners: a proof of concept study.

Learners who struggle with clinical decision making are often the most challenging to identify and remediate. While for some learners, struggles can be directly traced to a poor knowledge base, for many others, it is more difficult to understand the reason for their struggles. One of the main component of effective decision making is access to accurate and complete clinical information. The electronic health record (EHR) is the main source of clinical information and, with its widespread adoption, has come increased realisation that a large fraction of users have difficulty in effectively gathering and subsequently processing information out of the EHR. We previously documented that high-fidelity EHR-based simulation improves EHR usability and, when combined with eye and screen tracking, generates important measures of usability. We hypothesised that the same simulation exercise could help distinguish whether learners had difficulty in knowledge, information gathering or information processing. We report the results of the first three struggling learners who participated in this exercise. In each case, the simulation was able to ‘diagnose’ the aetiology for the learners’ struggle and assist in formulating an appropriate solution. We suggest that high-fidelity EHR-based simulation can be a powerful tool in the standard approach to understanding struggling learners.

Exploring Workarounds Related to Electronic Health Record System Usage: A Study Protocol

BackgroundHealth care providers resort to informal temporary practices known as workarounds for handling exceptions to normal workflow that are unintentionally imposed by electronic health record (EHR) systems. Although workarounds may seem favorable at first sight, they are generally suboptimal and may jeopardize patient safety, effectiveness, and efficiency of care. Identifying workarounds and understanding their motivations, scope, and impact is pivotal to support the design of user-friendly EHRs and achieve closer alignment between EHRs and work contexts.ObjectiveWe propose a study protocol to identify EHR workarounds and subsequently determine their scope and impact on health care providers’ workflows, patient safety, effectiveness, and efficiency of care. First, knowing whether a workaround solely affects the health care provider who devised it, or whether its effects extends beyond the EHR user to the work context of other health care providers, is key to accurately assessing its degree of influence on the overall patient care workflow. Second, knowing whether the consequence of an EHR workaround is favorable or unfavorable provides insights into how to address EHR-related safety, effectiveness, and efficiency concerns. Knowledge of both perspectives can provide input on optimizing EHR designs.MethodsIn the study, a combination of direct observations, semistructured interviews, and qualitative coding techniques will be used to identify, analyze, and classify EHR workarounds. The research project will be conducted within three distinct pediatric care processes and settings at a large university hospital.ResultsData was collected using the described approach from January 2016 to March 2017. Data analysis is underway and is expected to be completed in May 2017. We aim to report the results of this study in a follow-up publication.ConclusionsThis study protocol provides a grounded framework to explore EHR workarounds from a holistic and integral perspective. Insights from this study can inform the design and redesign of EHRs to further align with work contexts of healthcare professionals, and subsequently lead to better organization and safer provision of care.

The Effect of Procedural and Technological Security Countermeasures on the Propensity to Misuse Medical Data

As healthcare providers seek to comply with HIPAA and endeavor to secure their data from external breaches, they also need to realize that another threat to misuse of this data is inappropriate internal use by employees. Not all instances of misuse constitute a HIPAA violation, but they have the potential to become one. Medical data misuse by employees can be alleviated and curbed through the appropriate use of procedural and technological countermeasures. This paper seeks to determine whether electronic health records (EHR) policy and auditing procedures play a role in the propensity of providers to misuse medical data. Through an on-line survey of US physicians, nurses, medical students, and nursing students, using four case vignettes representing various forms of misuse, this research found that providers who were more aware of institutional security policy were more likely to adhere to policies than their counterparts who were not similarly informed. Likewise, providers who believed that their organizations monitored their EHR usage were less likely to engage in misuse than their counterparts who believed they were not monitored. The findings underscore the need for healthcare organizations to emphasize the importance of HIPAA compliance, and inform employees about the steps that the institution takes to maintain compliance, both from a procedural as well as technological standpoint. This study suggests that increasing the awareness of security and policy measures among employees is a vital part of preventing misuse.

Physician activity during outpatient visits and subjective workload

We describe methods for capturing and analyzing EHR use and clinical workflow of physicians during outpatient encounters and relating activity to physicians' self-reported workload. We collected temporally-resolved activity data including audio, video, EHR activity, and eye-gaze along with post-visit assessments of workload. These data are then analyzed through a combination of manual content analysis and computational techniques to temporally align streams, providing a range of process measures of EHR usage, clinical workflow, and physician-patient communication. Data was collected from primary care and specialty clinics at the Veterans Administration San Diego Healthcare System and UCSD Health, who use Electronic Health Record (EHR) platforms, CPRS and Epic, respectively. Grouping visit activity by physician, site, specialty, and patient status enables rank-ordering activity factors by their correlation to physicians' subjective work-load as captured by NASA Task Load Index survey. We developed a coding scheme that enabled us to compare timing studies between CPRS and Epic and extract patient and visit complexity profiles. We identified similar patterns of EHR use and navigation at the 2 sites despite differences in functions, user interfaces and consequent coded representations. Both sites displayed similar proportions of EHR function use and navigation, and distribution of visit length, proportion of time physicians attended to EHRs (gaze), and subjective work-load as measured by the task load survey. We found that visit activity was highly variable across individual physicians, and the observed activity metrics ranged widely as correlates to subjective workload. We discuss implications of our study for methodology, clinical workflow and EHR redesign.

Towards secure and flexible EHR sharing in mobile health cloud under static assumptions

Electronic health record (EHR) systems are promising in the management of individual’s health. However, before widely deployed in practical applications, EHR systems have to tackle the privacy and efficiency challenges. Most of existing EHR sharing schemes suffer from severe efficiency drawbacks, resulting in inapplicability in mobile EHR system. Furthermore, the security assumptions in the previous schemes are usually based on non-static assumptions. In this paper, we propose a flexible EHR sharing scheme supporting offline encryption of EHR and outsourced decryption of EHR ciphertexts in mobile cloud computing. The proposed scheme is proven secure in the random oracle model under the static decisional bilinear Diffie–Hellman assumption. In our EHR sharing system, an EHR owner only need one multiplication in bilinear groups to generate the final EHR ciphertexts based on the offline ciphertexts computation, and an EHR user can easily decrypt the EHR cipheretext without requiring bilinear pairing operations based on the transformed ciphertexts from the EHR cloud. Our EHR sharing scheme allows access structures encoded in linear secret sharing schemes. Performance comparisons indicate that our scheme is very suitable for mobile health clouds.

ELECTRONIC HEALTH RECORD SYSTEMS;

Introduction: e-Health is a combination of medical informatics, public health,business and information technology. Health information technology has increased theproductivity by reengineering of health care but it requires new measurement tools to monitorthe impact of it .e-health is not only for the development of technologies but also it includesproper planning, thinking, broad thinking to improve healthcare services with the help ofinformation and communication technology. Objectives: 1) To assess the perceptions ofphysicians towards the use, effectiveness and efficiency of EHR 2) To identify the differencesbetween electronic and paper based records 3) To evaluate the usage of Electronic HealthRecords.4) To analyze satisfaction and challenges face by the physicians using EHR. ResearchDesign: This is an Exploratory and Descriptive Research. In this study hybrid research methodis used which includes qualitative and quantitative research methods. Sampling technique:For this study, a purposive sample of 43 physicians was selected. The sample size was 60but 17 responses were incomplete so they were excluded and the final sample size was 43.Data was collected from two different hospitals of Pakistan which include the physicians fromShaukat Khanum Memorial Cancer Hospital and Research Centre, and Indus Hospital. Of the43 participants, 51% were from Indus Hospital and 49% were from Shaukat Khanum MemorialCancer Hospital and Research Centre. Instrument: A structured questionnaire was used tocollect data and it was collected by email responses and direct interview. EHR Questionnaire:A questionnaire was used in the study. The EHR Questionnaire has comprised of 24 items. Thisquestionnaire was developed by Msukwa. B.K.Martin.1 Data Analysis: Data analysis was doneby Statistical Package for Social Sciences (SPSS) and Microsoft Excel. Procedure: The sampleconsisted of physicians from Shaukat Khanum Memorial Cancer Hospital and Research Centre,and Indus Hospital from Karachi. EHR is a new technology and hospitals are moving towardsit, some are under process and very few like the above mentioned hospitals are using it. Thequestionnaire was not complicated. It was a structured questionnaire with easy questions withmultiple options to fill in. Respondents were also acknowledged for their cooperation andparticipation in the study. Conclusion: EHR should be used effectively, proper training is neededto ensure that physicians are able to operate the system and can have maximum benefits fromthe technology by utilizing all its applications. The government should encourage adoption ofElectronic Health l Records in Pakistan by developing a public-private partnership. The studyfocused also on EHR effectiveness by checking the working of EHR its quick and satisfactoryresults its accuracy, adequacy, timeliness, user- friendliness, availability and reliability.

Usability Evaluation of Electronic Health Record System around Clinical Notes Usage-An Ethnographic Study.

Background A substantial gap exists between current Electronic Health Record (EHR) usability and potential optimal usability. One of the fundamental reasons for this discrepancy is poor incorporation of a User-Centered Design (UCD) approach during the Graphical User Interface (GUI) development process. Objective To evaluate usability strengths and weaknesses of two widely implemented EHR GUIs for critical clinical notes usage tasks. Methods Twelve Internal Medicine resident physicians interacting with one of the two EHR systems (System-1 at Location-A and System-2 at Location-B) were observed by two usability evaluators employing an ethnographic approach. User comments and observer findings were analyzed for two critical tasks: (1) clinical notes entry and (2) related information-seeking tasks. Data were analyzed from two standpoints: (1) usability references categorized by usability evaluators as positive, negative, or equivocal and (2) usability impact of each feature measured through a 7-point severity rating scale. Findings were also validated by user responses to a post observation questionnaire. Results For clinical notes entry, System-1 surpassed System-2 with more positive (26% vs. 12%) than negative (12% vs. 34%) usability references. Greatest impact features on EHR usability (severity score pertaining to each feature) for clinical notes entry were: autopopulation (6), screen options (5.5), communication (5), copy pasting (4.5), error prevention (4.5), edit ability (4), and dictation and transcription (3.5). Both systems performed equally well on information-seeking tasks and features with greatest impacts on EHR usability were navigation for notes (7) and others (e.g., looking for ancillary data; 5.5). Ethnographic observations were supported by follow-up questionnaire responses. Conclusion This study provides usability-specific insights to inform future, improved, EHR interface that is better aligned with UCD approach.

Usability Evaluation of Laboratory Information Systems

Background: Numerous studies have revealed widespread clinician frustration with the usability of electronic health records (EHRs) that is counterproductive to adoption of EHR systems to meet the aims of health-care reform. With poor system usability comes increased risk of negative unintended consequences. Usability issues could lead to user error and workarounds that have the potential to compromise patient safety and negatively impact the quality of care.[1] While there is ample research on EHR usability, there is little information on the usability of laboratory information systems (LISs). Yet, LISs facilitate the timely provision of a great deal of the information needed by physicians to make patient care decisions.[2] Medical and technical advances in genomics that require processing of an increased volume of complex laboratory data further underscore the importance of developing user-friendly LISs. This study aims to add to the body of knowledge on LIS usability. Methods: A survey was distributed among LIS users at hospitals across the United States. The survey consisted of the ten-item System Usability Scale (SUS). In addition, participants were asked to rate the ease of performing 24 common tasks with a LIS. Finally, respondents provided comments on what they liked and disliked about using the LIS to provide diagnostic insight into LIS perceived usability. Results: The overall mean SUS score of 59.7 for the LIS evaluated is significantly lower than the benchmark of 68 (P < 0.001). All LISs evaluated received mean SUS scores below 68 except for Orchard Harvest (78.7). While the years of experience using the LIS was found to be a statistically significant influence on mean SUS scores, the combined effect of years of experience and LIS used did not account for the statistically significant difference in the mean SUS score between Orchard Harvest and each of the other LISs evaluated. Conclusions: The results of this study indicate that overall usability ofLISs is poor. Usability lags that of systems evaluated across 446 usability surveys.

A New EHR Training Curriculum and Assessment for Pediatric Residents.

Background Conventional classroom Electronic Health Record (EHR) training is often insufficient for new EHR users. Studies suggest that enhanced training with a hands-on approach and closely supported clinical use is beneficial. Objectives Our goals were to develop an enhanced EHR learning curriculum for Post Graduate Year 1 (PGY1) residents and measure changes in EHR skill proficiency, efficiency, and self-efficacy. Methods A novel three-phase, multimodal enhanced EHR curriculum was designed for a cohort of PGY1 residents. After basic training, residents began phase 1 of enhanced training, including demonstrations, live practice, and order set review. Phase 2 involved skills-oriented assignments, role playing, and medication entry. Phase 3 included shadowing, scribing histories, and supervised order entry. Residents' EHR skills and attitudes were measured and compared before and after the enhanced curriculum via proficiency test and a survey of efficiency and self-efficacy. Results Nineteen of 26 PGY1 residents participated in the study (73%). There was significant improvement in mean proficiency scores and two of the five individual proficiency scores. There were significant improvements in most efficiency survey responses from pre- to postintervention. For the self-efficacy presurvey, many PGY1s reported to be “very” or “somewhat confident” performing each of the five tasks, and perceptions did not improve or worsened on most postsurvey responses. The greatest resource was the time required to design and deliver the enhanced training. Conclusion An enhanced training curriculum along with a proficiency assessment was developed and described here. An enhanced training curriculum significantly improved PGY1 EHR efficiency and some measures of proficiency but not self-efficacy. This intervention may support improved EHR-related clinic workflows, which ultimately could enable residents and preceptors to prioritize patient care and time for clinical education.

FIN-TIERA: A Tool for Assessing Technology Induced Errors.

Due to the complexity of healthcare processes, the potential for Health Information Systems (HIS) to cause technology-induced errors is a growing concern. Health Information Technology (HIT) errors nearly always threaten good patient care and can lead to patient harm. Instruments to allow hospitals to proactively identify areas of Electronic Health Records (EHR) safety, to set priorities and to intervene before incidents occur are currently underdeveloped. The aim was to design a Finnish questionnaire to measure EHR users' perceptions of common EHR-related safety concerns in a specialized hospital district context through the lens of the theory of socio-technical dimensions. Moreover, the aim was to measure its reliability by assessing its internal consistency and validity, namely its content and construct validity. We constructed the instrument, based on the socio-technical theory and Sittig and Singh's study findings, through a multi-stage process, and expert panels evaluated it to ensure its content validity. The final questionnaire consisted of eight error types to be assessed on a qualitative risk matrix scale. We used a cross-sectional design to test its psychometric properties. Application of the FIN-TIERA Questionnaire to a sample of 2864 clinicians in 2015 then served to evaluate the instrument's reliability as well as its construct validity. All eight multi-item scales showedhigh internal consistency (range α > 0.798-0.932 and CR 0.845-0.983). The average variance extracted (AVE) served to assess the confirmatory factor analysis (CFA). The results of the model fit with AGFI = .86, CFI = .898, RMSEA = .052, SRMR = .048 were deemed acceptable. For all factors, AVE yielded values > 0.5, which indicates adequate convergence and supports convergent validity. Discriminant validity was established for five out of a total of eight latent variables. FIN-TIERA is a new multi-dimensional instrument which may be a useful tool for assessing risk in EHR. Our testing shows its potential for use in-hospital settings: the involvement of EHR users demonstrated initial reliability and validity. Further research is recommended to assess the instrument's psychometric properties.

Knowledge Acquisition for Electronic Health Records on cloud

Every Electronic Health Record (EHR) System has functionalities which protect patient’s data and drug related information prescribed at the time of medical diagnosis. Decision support system capabilities of the system provide necessary paperless handling support for the health information of a large number of patients. The extensive search on the practice of medical data indicates that there is a steep trend in the electronic health record usage. There is quite a number of EHR software available which are used as a Service globally, but many practitioners are not aware of selecting the right EHR SaaS product. Hence, there is a need to identify the best EHR SaaS from a pool of Software service products. To enhance the search of getting the best possible EHR SaaS product in this paper, researchers have adapted the novel way of using predefined attributes of these products and finding the relationship between them. Further, they are grouped into clusters depending on the rating, customer reviews, record of attested customers, eligible user professionals are guided in selecting a particular EHR SaaS.

Progress in adopting EHR in Saudi eastern region private hospitals

In general, the difference in the level of adoption, implementation, and use of technology between government and private sectors is common knowledge. The concern of this article is assessing the level and extent of usage of Electronic Health Records (EHR) in private sector hospitals in the EP of Saudi Arabia. The number of hospitals with EHR is increasing year by year and more functionality is observed in their use. The problems faced in accelerating the process of EHR adoption are likely to be the same as those in other countries including physicians’ resistance, lack of technical support, and others. To contribute toward the improvement of the uptake of EHR, there is more need for a systematic macro or national approach to encourage or push the hospitals to adopt such technology.Objectives: The objectives of this study were to determine (1) the extent and diffusion of EHR in private sector hospitals in the eastern province and (2) to explore the main features of adopting EHR and more specifically the obstacles, and problems in this regard.Methods: A comprehensive survey was developed and sent to hospital stakeholders to collect their opinions on the current status of the adoption and usage of EHR.Results: The private hospitals are faster in adopting and using EHR, compared to our previous study on public hospitals of the region.Conclusions: The results suggest that private hospitals are more flexible in adopting and running the EHR. A periodic assessment of EHR status should be performed as an encouraging/ enforcing policies can significantly increase the rate of adoption of EHR systems.

Linking macro-level goals to micro-level routines: EHR-enabled transformation of primary care services

Information and communication technologies are known to be instrumental in the enhancement of healthcare management capabilities in developing countries. Turkey - a developing country - has undergone a major healthcare transformation marked by the redesign of primary care delivery and the implementation of a nation-wide Electronic Health Records (EHR) system. In this research, presenting Turkey's case, we investigate the consequences of EHR implementation in developing countries. We argue that to better understand the consequences, we need to link macro-level healthcare goals with micro-level system usage behaviors that actualize the macro-level goals or alternatively result in unintended negative health outcomes. We posit that this linkage is achieved through the meso-level structures, namely the EHR and the organizational context, in which it is embedded. Hence, we examine the EHR's role in this relationship. Our findings indicate that EHR usage both enables and constrains the achievement of clinicians' professional goals in the context of primary care delivery. Moreover, goal alignment between the government agency as the designer of the system and the clinicians influence the outcomes of the EHR-enabled transformation. When the healthcare goals are aligned, the system enables the clinicians to achieve their professional goals and their system usage behaviors converge, contributing to improvements in health outcomes. Contrarily, when the goals are misaligned, the system constrains goal achievement and the clinicians show divergent usage behaviors, including goal abandonment. In turn, goal abandonment may lead to negative consequences and even adversely affect the achievement of population-level healthcare goals in the long run.

Natural Language Processing-Enabled and Conventional Data Capture Methods for Input to Electronic Health Records: A Comparative Usability Study.

BackgroundThe process of documentation in electronic health records (EHRs) is known to be time consuming, inefficient, and cumbersome. The use of dictation coupled with manual transcription has become an increasingly common practice. In recent years, natural language processing (NLP)–enabled data capture has become a viable alternative for data entry. It enables the clinician to maintain control of the process and potentially reduce the documentation burden. The question remains how this NLP-enabled workflow will impact EHR usability and whether it can meet the structured data and other EHR requirements while enhancing the user’s experience.ObjectiveThe objective of this study is evaluate the comparative effectiveness of an NLP-enabled data capture method using dictation and data extraction from transcribed documents (NLP Entry) in terms of documentation time, documentation quality, and usability versus standard EHR keyboard-and-mouse data entry.MethodsThis formative study investigated the results of using 4 combinations of NLP Entry and Standard Entry methods (“protocols”) of EHR data capture. We compared a novel dictation-based protocol using MediSapien NLP (NLP-NLP) for structured data capture against a standard structured data capture protocol (Standard-Standard) as well as 2 novel hybrid protocols (NLP-Standard and Standard-NLP). The 31 participants included neurologists, cardiologists, and nephrologists. Participants generated 4 consultation or admission notes using 4 documentation protocols. We recorded the time on task, documentation quality (using the Physician Documentation Quality Instrument, PDQI-9), and usability of the documentation processes.ResultsA total of 118 notes were documented across the 3 subject areas. The NLP-NLP protocol required a median of 5.2 minutes per cardiology note, 7.3 minutes per nephrology note, and 8.5 minutes per neurology note compared with 16.9, 20.7, and 21.2 minutes, respectively, using the Standard-Standard protocol and 13.8, 21.3, and 18.7 minutes using the Standard-NLP protocol (1 of 2 hybrid methods). Using 8 out of 9 characteristics measured by the PDQI-9 instrument, the NLP-NLP protocol received a median quality score sum of 24.5; the Standard-Standard protocol received a median sum of 29; and the Standard-NLP protocol received a median sum of 29.5. The mean total score of the usability measure was 36.7 when the participants used the NLP-NLP protocol compared with 30.3 when they used the Standard-Standard protocol.ConclusionsIn this study, the feasibility of an approach to EHR data capture involving the application of NLP to transcribed dictation was demonstrated. This novel dictation-based approach has the potential to reduce the time required for documentation and improve usability while maintaining documentation quality. Future research will evaluate the NLP-based EHR data capture approach in a clinical setting. It is reasonable to assert that EHRs will increasingly use NLP-enabled data entry tools such as MediSapien NLP because they hold promise for enhancing the documentation process and end-user experience.

Usability problems do not heal by themselves: National survey on physicians’ experiences with EHRs in Finland

PurposeSurvey studies of health information systems use tend to focus on availability of functionalities, adoption and intensity of use. Usability surveys have not been systematically conducted by any healthcare professional groups on a national scale on a repeated basis. This paper presents results from two cross-sectional surveys of physicians’ experiences with the usability of currently used EHR systems in Finland. The research questions were: To what extent has the overall situation improved between 2010 and 2014? What differences are there between healthcare sectors? MethodsIn the spring of 2014, a survey was conducted in Finland using a questionnaire that measures usability and respondents’ user experiences with electronic health record (EHR) systems. The survey was targeted to physicians who were actively doing clinical work. Twenty-four usability-related statements, that were identical in 2010 and 2014, were analysed from the survey. The respondents were also asked to give an overall rating of the EHR system they used. The study data comprised responses from 3081 physicians from the year 2014 and from 3223 physicians in the year 2010, who were using the nine most commonly used EHR system brands in Finland. ResultsPhysicians’ assessments of the usability of their EHR system remain as critical as they were in 2010. On a scale from 1 (‘fail’) to 7 (‘excellent’) the average of overall ratings of their principally used EHR systems varied from 3.2 to 4.4 in 2014 (and in 2010 from 2.5 to 4.3). The results show some improvements in the following EHR functionalities and characteristics: summary view of patient’s health status, prevention of errors associated with medication ordering, patient’s medication list as well as support for collaboration and information exchange between the physician and the nurses. Even so, support for cross-organizational collaboration between physicians and for physician-patient collaboration were still considered inadequate. Satisfaction with technical features had not improved in four years. The results show marked differences between the EHR system brands as well as between healthcare sectors (private sector, public hospitals, primary healthcare). Compared to responses from the public sector, physicians working in the private sector were more satisfied with their EHR systems with regards to statements about user interface characteristics and support for routine tasks. Overall, the study findings are similar to our previous study conducted in 2010. ConclusionsSurveys about the usability of EHR systems are needed to monitor their development at regional and national levels. To our knowledge, this study is the first national eHealth observatory questionnaire that focuses on usability and is used to monitor the long-term development of EHRs. The results do not show notable improvements in physician’s ratings for their EHRs between the years 2010 and 2014 in Finland. Instead, the results indicate the existence of serious problems and deficiencies which considerably hinder the efficiency of EHR use and physician’s routine work. The survey results call for considerable amount of development work in order to achieve the expected benefits of EHR systems and to avoid technology-induced errors which may endanger patient safety. The findings of repeated surveys can be used to inform healthcare providers, decision makers and politicians about the current state of EHR usability and differences between brands as well as for improvements of EHR usability. This survey will be repeated in 2017 and there is a plan to include other healthcare professional groups in future surveys.

Barriers to comparing the usability of electronic health records.

Despite the widespread adoption of electronic health records (EHRs), usability of many EHRs continues to be suboptimal, with some vendors failing to meet usability standards, resulting in clinician frustration and patient safety hazards. In an effort to increase EHR vendor competition on usability, recommendations have been made and legislation drafted to develop comparison tools that would allow purchasers to better understand the usability of EHR products prior to purchase. Usability comparison can be based on EHR vendor design and development processes, vendor usability testing as part of the Office of the National Coordinator for Health Information Technology certification program, and usability of implemented products. Barriers exist within the current certified health technology program that prevent effective comparison of usability during each of these stages. We describe the importance of providing purchasers with improved information about EHR usability, barriers to making usability comparisons, and solutions to overcome these barriers.

New Unintended Adverse Consequences of Electronic Health Records.

Although the health information technology industry has made considerable progress in the design, development, implementation, and use of electronic health records (EHRs), the lofty expectations of the early pioneers have not been met. In 2006, the Provider Order Entry Team at Oregon Health & Science University described a set of unintended adverse consequences (UACs), or unpredictable, emergent problems associated with computer-based provider order entry implementation, use, and maintenance. Many of these originally identified UACs have not been completely addressed or alleviated, some have evolved over time, and some new ones have emerged as EHRs became more widely available. The rapid increase in the adoption of EHRs, coupled with the changes in the types and attitudes of clinical users, has led to several new UACs, specifically: complete clinical information unavailable at the point of care; lack of innovations to improve system usability leading to frustrating user experiences; inadvertent disclosure of large amounts of patient-specific information; increased focus on computer-based quality measurement negatively affecting clinical workflows and patient-provider interactions; information overload from marginally useful computer-generated data; and a decline in the development and use of internally-developed EHRs. While each of these new UACs poses significant challenges to EHR developers and users alike, they also offer many opportunities. The challenge for clinical informatics researchers is to continue to refine our current systems while exploring new methods of overcoming these challenges and developing innovations to improve EHR interoperability, usability, security, functionality, clinical quality measurement, and information summarization and display.