Electronic Health Record Vendors Research Articles

Barriers and facilitators of the use of clinical informatics resources to facilitate pharmacogenomic implementation in resource-limited settings.

Understand perceived barriers to and facilitators of using clinical informatics applications for pharmacogenomic (PGx) implementation in resource-limited settings. We conducted a qualitative research study using a semi-structured interview guide informed by the Consolidated Framework for Implementation Research (CFIR). Interview questions assessed CFIR contextual determinants related to: electronic health record (EHR) infrastructure; clinical informatics personnel and resources; EHR integration of PGx test results; PGx clinical decision support (CDS) tools; institutional resources; and partner receptivity. Transcripts were coded and analyzed to identify themes. We interviewed 24 clinical informaticists and executive leaders working in rural or underserved health care settings in Montana (n = 15) and Colorado (n = 9) and identified three major themes: (1) EHR infrastructure limitations, (2) insufficient supporting resources, and (3) unique contextual considerations for resource-limited settings. EHR infrastructure limitations included limited agency related to EHR build and interoperability concerns. Theme 1 highlighted challenges associated with integrating structured data into the EHR and inadequate vendor support. Theme 2 included limited familiarity with PGx across the care team, cost concerns, and allocation of non-financial resources. Theme 3 highlighted perceptions about the clinical utility of PGx within rural and underrepresented populations. Potential facilitators, such as being able to act nimbly, were found to coexist among the reported barriers. Our results provide insight into the clinical informatics infrastructure in resource-limited settings and identify unique considerations for clinical informatics-facilitated PGx implementation. Future efforts in these settings should consider innovative partnerships and strategies to leverage facilitators and minimize barriers associated with integrating PGx CDS applications.

Use of a Set-up Fee to Encourage Survey Participation and Electronic Health Record Submission for a National Health Care Survey.

In 2021, the National Ambulatory Medical Care Survey Health Center (NAMCS HC) Component modernized its data collection and began collecting clinical visit data from health centers using transmission of electronic health record (EHR) data. With this redesign, there are potential cost implications for a health center to participate. Beginning in 2021, a one-time set-up fee (i.e., payment) of up to $10,000 was offered to centers who participated in the NAMCS HC Component. Starting in 2022, a Set-up Fee Questionnaire was used to capture data on the use of this money. Results show on average the fee appeared adequate in covering participation costs, with the fee most often used to cover costs of health center and EHR vendor information technology staff. Although this fee was offered only during the initial year of participation, retention rates for centers appeared high. Implications from the findings of this case study on use of a set-up fee in establishment surveys are also briefly discussed.

Physicians' Experiences of EHR Technical Quality: Results from Four Large Cross-Sectional Surveys in 2010-2021.

Unexpected downtime and long response times of electronic health record (EHR) systems not only impact user satisfaction and clinicians' work efficiency but also bring about potential harm for patients. Despite improvements in the performance of EHR systems' architecture, hardware, and networks, technical challenges continue to cause problems. We explored the end-user experiences of EHR technical functionality and quality from four large national cross-sectional surveys conducted among Finnish physicians in 2010-21. The results were analyzed by healthcare sector/specialty groups. In most groups, the experiences of stability and reaction speed became worse in 2010-17, which is readily explained by the implementation of the national patient data repository services, but improvements were seen in 2021, suggesting that EHR vendors have solved at least some of the slowness problems. The proportion of physicians reporting having experienced faulty system function with potential or actualized harm for the patient had decreased in operative and medical specialties and in the private sector but remained stable in other groups. Our findings underline the importance of continuing to develop technical qualities - including the implementations of national integrations.

A human centered design approach to define and measure documentation quality using an EHR virtual simulation.

Electronic health record (EHR) documentation serves multiple functions, including recording patient health status, enabling interprofessional communication, supporting billing, and providing data to support the quality infrastructure of a Learning Healthcare System. There is no definition and standardized method to assess documentation quality in EHRs. Using a human-centered design (HCD) approach, we define and describe a method to measure documentation quality. Documentation quality was defined as timely, accurate, user-centered, and efficient. Measurement of quality used a virtual simulated standardized patient visit via an EHR vendor platform. By observing and recording documentation efforts, nurse practitioners (NPs) (N = 12) documented the delivery of an Age-Friendly Health System (AFHS) 4Ms (what Matters, Medication, Mentation, and Mobility) clinic visit using a standardized case. Results for timely documentation indicated considerable variability in completion times of documenting the 4Ms. Accuracy varied, as there were many types of episodes of erroneous documentation and extra time in seconds in documenting the 4Ms. The type and frequency of erroneous documentation efforts were related to navigation burden when navigating to different documentation tabs. The evaluated system demonstrated poor usability, with most participants scoring between 60 and 70 on the System Usability Scale (SUS). Efficiency, measured as click burden (the number of clicks used to navigate through a software system), revealed significant variability in the number of clicks required, with the NPs averaging approximately 13 clicks above the minimum requirement. The HCD methodology used in this study to assess the documentation quality proved feasible and provided valuable information on the quality of documentation. By assessing the quality of documentation, the gathered data can be leveraged to enhance documentation, optimize user experience, and elevate the quality of data within a Learning Healthcare System.

Electronic Health Record Usability, Satisfaction, and Burnout for Family Physicians

Electronic health record (EHR) work has been associated with decreased physician well-being. Understanding the association between EHR usability and physician satisfaction and burnout, and whether team and technology strategies moderate this association, is critical to informing efforts to address EHR-associated physician burnout. To measure family physician satisfaction with their EHR and EHR usability across functions and evaluate the association of EHR usability with satisfaction and burnout, as well as the moderating association of 4 team and technology EHR efficiency strategies. This study uses data from a cross-sectional survey conducted from December 12, 2021, to October 17, 2022, of all family physicians seeking American Board of Family Medicine recertification in 2022. Physicians perceived EHR usability across 6 domains, as well as adoption of 4 EHR efficiency strategies: scribes, support from other staff, templated text, and voice recognition or transcription. Physician EHR satisfaction and frequency of experiencing burnout measured with a single survey item ("I feel burned out from my work"), with answers ranging from "never" to "every day." Of the 2067 physicians (1246 [60.3%] younger than 50 years; 1051 men [50.9%]; and 1729 [86.0%] practicing in an urban area) who responded to the survey, 562 (27.2%) were very satisfied and 775 (37.5%) were somewhat satisfied, while 346 (16.7%) were somewhat dissatisfied and 198 (9.6%) were very dissatisfied with their EHR. Readability of information had the highest usability, with 543 physicians (26.3%) rating it as excellent, while usefulness of alerts had the lowest usability, with 262 physicians (12.7%) rating it as excellent. In multivariable models, good or excellent usability for entering data (β = 0.09 [95% CI, 0.05-0.14]; P < .001), alignment with workflow processes (β = 0.11 [95% CI, 0.06-0.16]; P < .001), ease of finding information (β = 0.14 [95% CI, 0.09-0.19]; P < .001), and usefulness of alerts (β = 0.11 [95% CI, 0.06-0.16]; P < .001) were associated with physicians being very satisfied with their EHR. In addition, being very satisfied with the EHR was associated with reduced frequency of burnout (β = -0.64 [95% CI, -1.06 to -0.22]; P < .001). In moderation analysis, only physicians with highly usable EHRs saw improvements in satisfaction from adopting efficiency strategies. In this survey study of physician EHR usability and satisfaction, approximately one-fourth of family physicians reported being very satisfied with their EHR, while another one-fourth reported being somewhat or very dissatisfied, a concerning finding amplified by the inverse association between EHR satisfaction and burnout. Electronic health record-based alerts had the lowest reported usability, suggesting EHR vendors should focus their efforts on improving alerts. Electronic health record efficiency strategies were broadly adopted, but only physicians with highly usable EHRs realized gains in EHR satisfaction from using these strategies, suggesting that EHR burden-reduction interventions are likely to have heterogenous associations across physicians with different EHRs.

Development and application of Breadth-Depth-Context (BDC), a conceptual framework for measuring technology engagement with a qualified clinical data registry.

Despite the proliferation of dashboards that display performance data derived from Qualified Clinical Data Registries (QCDR), the degree to which clinicians and practices engage with such dashboards has not been well described. We aimed to develop a conceptual framework for assessing user engagement with dashboard technology and to demonstrate its application to a rheumatology QCDR. We developed the BDC (Breadth-Depth-Context) framework, which included concepts of breadth (derived from dashboard sessions), depth (derived from dashboard actions), and context (derived from practice characteristics). We demonstrated its application via user log data from the American College of Rheumatology's Rheumatology Informatics System for Effectiveness (RISE) registry to define engagement profiles and characterize practice-level factors associated with different profiles. We applied the BDC framework to 213 ambulatory practices from the RISE registry in 2020-2021, and classified practices into 4 engagement profiles: not engaged (8%), minimally engaged (39%), moderately engaged (34%), and most engaged (19%). Practices with more patients and with specific electronic health record vendors (eClinicalWorks and eMDs) had a higher likelihood of being in the most engaged group, even after adjusting for other factors. We developed the BDC framework to characterize user engagement with a registry dashboard and demonstrated its use in a specialty QCDR. The application of the BDC framework revealed a wide range of breadth and depth of use and that specific contextual factors were associated with nature of engagement. Going forward, the BDC framework can be used to study engagement with similar dashboards.

Patient Portals Fail to Collect Structured Information About Who Else is Involved in a Person's Care.

The US health care delivery system does not systematically engage or support family or friend care partners. Meanwhile, the uptake and familiarity of portals to personal health information are increasing among patients. Technology innovations, such as shared access to the portal, use separate identity credentials to differentiate between patients and care partners. Although not well-known, or commonly used, shared access allows patients to identify who they do and do not want to be involved in their care. However, the processes for patients to grant shared access to portals are often limited or so onerous that interested patients and care partners often circumvent the process entirely. As a result, the vast majority of care partners resort to accessing portals using a patient's identity credentials-a "do-it-yourself" solution in conflict with a health systems' legal responsibility to protect patient privacy and autonomy. The personal narratives in this viewpoint (shared by permission) elaborate on quantitative studies and provide first-person snapshots of challenges faced by patients and families as they attempt to gain or grant shared access during crucial moments in their lives. As digital modalities increase patient roles in health care interactions, so does the importance of making shared access work for all stakeholders involved-patients, clinicians, and care partners. Electronic health record vendors must recognize that both patients and care partners are important users of their products, and health care organizations must acknowledge and support the critical contributions of care partners as distinct from patients.

Improved Accuracy/Completeness of EHR Race/Ethnicity Data: A Requisite Step to Address Disparities in Care.

Accurate and complete racial/ethnic data in the electronic health record are a requisite step to addressing disparities in neurologic care, and at local, regional, and national levels. The current data pertaining to the patients' race and ethnicity contained in the electronic health record are inadequate. This article outlines recommendations at the individual practice and electronic health record vendor level to improve documentation of race and ethnicity.

Evaluation of SNOMED CT Grouper Accuracy and Coverage in Organizing the Electronic Health Record Problem List by Clinical System: Observational Study.

The problem list (PL) is a repository of diagnoses for patients' medical conditions and health-related issues. Unfortunately, over time, our PLs have become overloaded with duplications, conflicting entries, and no-longer-valid diagnoses. The lack of a standardized structure for review adds to the challenges of clinical use. Previously, our default electronic health record (EHR) organized the PL primarily via alphabetization, with other options available, for example, organization by clinical systems or priority settings. The system's PL was built with limited groupers, resulting in many diagnoses that were inconsistent with the expected clinical systems or not associated with any clinical systems at all. As a consequence of these limited EHR configuration options, our PL organization has poorly supported clinical use over time, particularly as the number of diagnoses on the PL has increased. We aimed to measure the accuracy of sorting PL diagnoses into PL system groupers based on Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) concept groupers implemented in our EHR. We transformed and developed 21 system- or condition-based groupers, using 1211 SNOMED CT hierarchal concepts refined with Boolean logic, to reorganize the PL in our EHR. To evaluate the clinical utility of our new groupers, we extracted all diagnoses on the PLs from a convenience sample of 50 patients with 3 or more encounters in the previous year. To provide a spectrum of clinical diagnoses, we included patients from all ages and divided them by sex in a deidentified format. Two physicians independently determined whether each diagnosis was correctly attributed to the expected clinical system grouper. Discrepancies were discussed, and if no consensus was reached, they were adjudicated by a third physician. Descriptive statistics and Cohen κ statistics for interrater reliability were calculated. Our 50-patient sample had a total of 869 diagnoses (range 4-59; median 12, IQR 9-24). The reviewers initially agreed on 821 system attributions. Of the remaining 48 items, 16 required adjudication with the tie-breaking third physician. The calculated κ statistic was 0.7. The PL groupers appropriately associated diagnoses to the expected clinical system with a sensitivity of 97.6%, a specificity of 58.7%, a positive predictive value of 96.8%, and an F1-score of 0.972. We found that PL organization by clinical specialty or condition using SNOMED CT concept groupers accurately reflects clinical systems. Our system groupers were subsequently adopted by our vendor EHR in their foundation system for PL organization.

Foundation Models, Generative AI, and Large Language Models

We are in a booming era of artificial intelligence, particularly with the increased availability of technologies that can help generate content, such as ChatGPT. Healthcare institutions are discussing or have started utilizing these innovative technologies within their workflow. Major electronic health record vendors have begun to leverage large language models to process and analyze vast amounts of clinical natural language text, performing a wide range of tasks in healthcare settings to help alleviate clinicians' burden. Although such technologies can be helpful in applications such as patient education, drafting responses to patient questions and emails, medical record summarization, and medical research facilitation, there are concerns about the tools' readiness for use within the healthcare domain and acceptance by the current workforce. The goal of this article is to provide nurses with an understanding of the currently available foundation models and artificial intelligence tools, enabling them to evaluate the need for such tools and assess how they can impact current clinical practice. This will help nurses efficiently assess, implement, and evaluate these tools to ensure these technologies are ethically and effectively integrated into healthcare systems, while also rigorously monitoring their performance and impact on patient care.

Guiding Principles for Adolescent Web-Based Portal Access Policies: Interviews With Informatics Administrators.

Web-based patient portals are tools that could support adolescents in managing their health and developing autonomy. However, informatics administrators must navigate competing interests when developing portal access policies for adolescents and their parents. We aimed to assess the perspectives of informatics administrators on guiding principles for the development of web-based health care portal access policies in adolescent health care. We interviewed informatics administrators from US hospitals with ≥50 dedicated pediatric beds. We performed a thematic analysis of guiding principles for developing and implementing adolescent portal access policies. We interviewed 65 informatics leaders who represented 63 pediatric hospitals, 58 health care systems, 29 states, and 14,379 pediatric hospital beds. Participants described 9 guiding principles related to three overarching themes: (1) balancing confidentiality and other care needs, (2) balancing simplicity and granularity, and (3) collaborating and advocating. Participants described the central importance of prioritizing the health and safety of the adolescent while also complying with state and federal laws. However, there were differing beliefs about how to prioritize health and safety and what role parents should play in supporting the adolescent's health care. Participants also identified areas where clinicians and institutions can advocate for adolescents, especially with electronic health record vendors and legislators. Informatics administrators provided guiding principles for adolescent portal access policies that aimed to balance the competing needs of adolescent confidentiality and the usefulness of the portal. Portal access policies must prioritize the adolescent's health and safety while complying with state and federal laws. However, institutions must determine how to best enact these principles. Institutions and clinicians should strive for consensus on principles to strengthen advocacy efforts with institutional leadership, electronic health record vendors, and lawmakers.

Explaining Variability in Electronic Health Record Effort in Primary Care Ambulatory Encounters.

Electronic health record (EHR) user interface event logs are fast providing another perspective on the value and efficiency EHR technology brings to health care. Analysis of these detailed usage data has demonstrated their potential to identify EHR and clinical process design factors related to user efficiency, satisfaction, and burnout. This study aimed to analyze the event log data across 26 different health systems to determine the variability of use of a single vendor's EHR based on four event log metrics, at the individual, practice group, and health system levels. We obtained de-identified event log data recorded from June 1, 2018, to May 31, 2019, from 26 health systems' primary care physicians. We estimated the variability in total Active EHR Time, Documentation Time, Chart Review Time, and Ordering Time across health systems, practice groups, and individual physicians. In total, 5,444 physicians (Family Medicine: 3,042 and Internal Medicine: 2,422) provided care in a total of 2,285 different practices nested in 26 health systems. Health systems explain 1.29, 3.55, 3.45, and 3.30% of the total variability in Active Time, Documentation Time, Chart Review Time, and Ordering Time, respectively. Practice-level variability was estimated to be 7.96, 13.52, 8.39, and 5.57%, respectively, and individual physicians explained the largest proportion of the variability for those same outcomes 17.09, 27.49, 17.51, and 19.75%, respectively. The most variable physician EHR usage patterns occurs at the individual physician level and decreases as you move up to the practice and health system levels. This suggests that interventions to improve individual users' EHR usage efficiency may have the most potential impact compared with those directed at health system or practice levels.

Clinical Knowledge Model for the Prevention of Healthcare-Associated Venous Thromboembolism.

Knowledge models inform organizational behavior through the logical association of documentation processes, definitions, data elements, and value sets. The development of a well-designed knowledge model allows for the reuse of electronic health record data to promote efficiency in practice, data interoperability, and the extensibility of data to new capabilities or functionality such as clinical decision support, quality improvement, and research. The purpose of this article is to describe the development and validation of a knowledge model for healthcare-associated venous thromboembolism prevention. The team used FloMap, an Internet-based survey resource, to compare metadata from six healthcare organizations to an initial draft model. The team used consensus decision-making over time to compare survey results. The resulting model included seven panels, 41 questions, and 231 values. A second validation step included completion of an Internet-based survey with 26 staff nurse respondents representing 15 healthcare organizations, two electronic health record vendors, and one academic institution. The final knowledge model contained nine Logical Observation Identifiers Names and Codes panels, 32 concepts, and 195 values representing an additional six panels (groupings), 15 concepts (questions), and the specification of 195 values (answers). The final model is useful for consistent documentation to demonstrate the contribution of nursing practice to the prevention of venous thromboembolism.

Standardizing default electronic health record tools to improve safety for hospitalized patients with Parkinson's disease.

Electronic Health Record (EHR) systems are often configured to address challenges and improve patient safety for persons with Parkinson's disease (PWP). For example, EHR systems can help identify Parkinson's disease (PD) patients across the hospital by flagging a patient's diagnosis in their chart, preventing errors in medication and dosing through the use of clinical decision support, and supplementing staff education through care plans that provide step-by-step road maps for disease-based care of a specific patient population. However, most EHR-based solutions are locally developed and, thus, difficult to scale widely or apply uniformly across hospital systems. In 2020, the Parkinson's Foundation, a national and international leader in PD research, education, and advocacy, and Epic, a leading EHR vendor with more than 35% market share in the United States, launched a partnership to reduce risks to hospitalized PWP using standardized EHR-based solutions. This article discusses that project which included leadership from physician informaticists, movement disorders specialists, hospital quality officers, the Parkinson's Foundation and members of the Parkinson's community. We describe the best practice solutions developed through this project. We highlight those that are currently available as standard defaults or options within the Epic EHR, discuss the successes and limitations of these solutions, and consider opportunities for scalability in environments beyond a single EHR vendor. The Parkinson's Foundation and Epic launched a partnership to develop best practice solutions in the Epic EHR system to improve safety for PWP in the hospital. The goal of the partnership was to create the EHR tools that will have the greatest impact on outcomes for hospitalized PWP.

Provider Perspectives on Adolescent Confidentiality and the Electronic Health Record Postimplementation of the 21st Century Cures Act Final Rule

PurposeThe 21st Century Cures Act Final Rule mandates increased transparency and accessibility of the Electronic Health Record (EHR). This mandate has exacerbated tensions in adolescent healthcare between transparency and confidentiality. This study evaluates clinicians' perspectives on how well the EHR maintains confidentiality for adolescents in the post-Cures Act era. MethodsA web-based survey was distributed via the national listserv of the Society for Adolescent Health and Medicine in March–April 2022. English-speaking members practicing in the Unites States who used an EHR to document clinical visits with minors were eligible. The survey included questions about EHR training, features, and approach to information sharing with adolescent patients and proxies. ResultsParticipants included 97 respondents from 32 states. Most participants were physicians (98%) and identified themselves as attending (89%). Several EHR vendors were represented, although the majority used Epic (76%). As has been seen in prior studies, there remains significant variability in approaches to patient portal access for adolescent patients and their adult proxies. Respondents report that training around adolescent-specific privacy issues remains infrequent and is perceived as inadequate. Adolescent providers, despite feeling confident in navigating the EHR generally, continue to report low rates of confidence in how well their EHR may protect adolescent privacy. DiscussionClinicians have persistent concerns about adolescent confidentiality postimplementation of the 21st Century Cures Act. Sharing sufficient information while protecting adolescent confidentiality might require standardization by EHR vendors to improve granularity of proxy information sharing. Healthcare institutions must also commit to training providers on management of adolescent confidentiality.

Analysis of Inclusive Gender, Sexuality and Sexual Orientation Data Elements in Academic Electronic Health Records.

Findings from an analysis of three vended academic electronic health records used in health science education are presented in this article. The quality assurance project examined the lexical and semantic fit and content coverage of gender, sexuality, and sexual orientation data elements within the academic electronic health records. A semantic comparative content analysis using a cognitive walkthrough was conducted as a means of comparing the ideal set of gender, sexuality, and sexual orientation data elements with those found in the three vended academic electronic health records. The results indicated a need for alignment to the research literature, expert consensus, and technical standards similar to what is expected for electronic health records used in clinical practice because of a lack of ideal state data elements. The findings align with ongoing issues with bias and disparities seen in the care of the lesbian, gay, bisexual, and transgender population and a lack of diverse, inclusive media and teaching technologies in health science education. The quality project and findings can inform academic electronic health record vendors on how they can create more inclusive systems and bring awareness to healthcare educators about the potential for implicit and explicit bias in their teaching technologies.

Enhancing Simulation: A Roadmap for Integrating the Electronic Health Record into the Nurse Practitioner Curriculum

The electronic health record (EHR) is an important health information technology (IT) used to support efficient clinical workflows, patient safety, and quality of care. The EHR is an individual's medical chart stored in digital format for complete real-time information to reduce medical errors and improve outcomes. EHR technology is complex, and users may struggle with efficiently navigating the system for data retrieval, documentation, and time management. Academic institutions are positioned to collaborate with EHR vendors to offer training playgrounds in the curriculum that simulate the clinical interface and support readiness to practice in relevant technology-rich clinical environments. A strategically selected educational EHR vendor matched to the platforms used by major health care organizations may influence clinical partnerships and employment opportunities. EHR competency may alleviate some of the onboarding burden for health care institutions and new graduates at a time of role transition. This article provides strategies for leveraging health IT in the academic curriculum to prepare a technology-proficient workforce capable of meeting the needs of diverse individuals, populations, and healthcare systems.

Clinical Decision Support to Reduce Opioid Prescriptions for Dental Extractions using SMART on FHIR: Implementation Report.

Clinical decision support (CDS) has the potential to improve clinical decision-making consistent with evidence-based care. CDS can be designed to save health care providers time and help them provide safe and personalized analgesic prescribing. The aim of this report is to describe the development of a CDS system designed to provide dentists with personalized pain management recommendations to reduce opioid prescribing following extractions. The use of CDS is also examined. This study was conducted in HealthPartners, which uses an electronic health record (EHR) system that integrates both medical and dental information upon which the CDS application was developed based on SMART (Substitutable Medical Applications and Reusable Technologies) on FHIR (Fast Healthcare Interoperability Resources). The various tools used to bring relevant medical conditions, medications, patient history, and other relevant data into the CDS interface are described. The CDS application runs a drug interaction algorithm developed by our organization and provides patient-specific recommendations. The CDS included access to the state Prescription Monitoring Program database. The pain management CDS was implemented as part of a study examining opioid prescribing among patients undergoing dental extraction procedures from February 17, 2020, to May 14, 2021. Provider-level use of CDS at extraction encounters ranged from 0% to 87.4% with 12.1% of providers opening the CDS for no encounters, 39.4% opening the CDS for 1%-20% of encounters, 36.4% opening it for 21%-50% of encounters, and 12.1% opening it for 51%-87% of encounters. The pain management CDS is an EHR-embedded, provider-facing tool to help dentists make personalized pain management recommendations following dental extractions. The SMART on FHIR-based pain management CDS adapted well to the point-of-care dental setting and led to the design of a scalable CDS tool that is EHR vendor agnostic. ClinicalTrials.gov NCT03584789; https://clinicaltrials.gov/study/NCT03584789.

Experts' Perspectives on Use of Fast Healthcare Interoperable Resources for Computerized Clinical Decision Support.

Barriers to improving the US healthcare system include a lack of interoperability across digital health information and delays in seeking preventative and recommended care. Interoperability can be seen as the lynch pin to reducing fragmentation and improving outcomes related to digital health systems. The prevailing standard for information exchange to enable interoperability is the Health Level Seven International Fast Healthcare Interoperable Resources standard. To better understand Fast Healthcare Interoperable Resources within the context of computerized clinical decision support expert interviews of health informaticists were conducted and used to create a modified force field analysis. Current barriers and future recommendations to scale adoption of Fast Healthcare Interoperable Resources were explored through qualitative analysis of expert interviews. Identified barriers included variation in electronic health record implementation, limited electronic health record vendor support, ontology variation, limited workforce knowledge, and testing limitations. Experts recommended research funders require Fast Healthcare Interoperable Resource usage, development of an "app store," incentives for clinical organizations and electronic health record vendors, and Fast Healthcare Interoperable Resource certification development.

Identifying and Addressing Barriers to Implementing Core Electronic Health Record Use Metrics for Ambulatory Care: Virtual Consensus Conference Proceedings.

Precise, reliable, valid metrics that are cost-effective and require reasonable implementation time and effort are needed to drive electronic health record (EHR) improvements and decrease EHR burden. Differences exist between research and vendor definitions of metrics. PROCESS: We convened three stakeholder groups (health system informatics leaders, EHR vendor representatives, and researchers) in a virtual workshop series to achieve consensus on barriers, solutions, and next steps to implementing the core EHR use metrics in ambulatory care. CONCLUSION: Actionable solutions identified to address core categories of EHR metric implementation challenges include: (1) maintaining broad stakeholder engagement, (2) reaching agreement on standardized measure definitions across vendors, (3) integrating clinician perspectives, and (4) addressing cognitive and EHR burden. Building upon the momentum of this workshop's outputs offers promise for overcoming barriers to implementing EHR use metrics.