Electronic Health Record Implementation Research Articles

Factors correlate acceptance of applying electronic health solution records among emergency nurses

ABSTRACT Using Electronic Health Records results in better quality and safety in healthcare provided to patients. It enhances the productivity in health-care services and communication between health-care providers. Nurses are the largest group of health-care professionals anticipated to use Electronic Health Records during their work in health-care settings, including the emergency department. Thus, this study purposed to assess the factors that correlate acceptance of applying for Electronic Health Solutions Records among Jordanian emergency department nurses. A cross-sectional, descriptive correlational design was adopted. A total of 422 nurses participated in this study. A self-reported questionnaire included demographic data, acceptance of applying for Electronic Health Records, and acceptance-related factors of applying for this program were used to collect data. Findings showed that emergency nurses agreed on the acceptance of applying Electronic Health Records. There was a positive relationship between acceptance of applying Electronic Health Records and perceived usefulness, perceived ease of use, and nurses’ involvement. Thus, the correlated factors should be considered during the implementation of Electronic Health Records in any health-care institution, especially the emergency department to enhance the nurses’ acceptance of this system.

An electronic health record system implementation in a resource limited country-lessons learned.

Electronic health records have revolutionized the medical world by improving medical care, refining provider documentation, standardizing care, and minimizing sentinel events. Successful implementation of electronic health records remains a daunting task and requires careful strategic planning and buy-in from key stakeholders. Much has been published in resource-rich settings and high-income countries about implementations of electronic health records. However, little is known about the experience in resource-limited settings where challenges remain unique and distinct from other parts of the world. Our intention is to share lessons learned during implementation of a web-based electronic health record at a tertiary care center in Kenya.

Understanding EHR current status and challenges to a nationwide electronic health records implementation in Morocco

BackgroundElectronic health records (EHRs) are transforming and revolutionizing the healthcare industry. While developed countries have a high EHR adoption rate, developing countries like Morocco are still struggling on deploying it over the whole territory. ObjectivesGiven the lack of scientific contribution on the topic, this study aims to fill this gap by investigating the status of Electronic Health Record (EHR) systems in Morocco with a focus on usage scenarios, implementation approach, and barriers to its implementation. MethodsThis study is based on documentary analysis. The analyzed documents include the limited research papers available on the subject, data from local and international press, reports from health entities and project partners and data from the high commission of planning, which is the main administrative structure responsible for producing official statistics in Morocco. ResultsThe findings of this study unveil significant advancements in the deployment of EHR systems at the sub-national level in Morocco by adopting a “middle-out” implementation approach. Currently, EHR is utilized for clinical purposes within individual healthcare providers in a centralized manner. It is also used to some extent for epidemiological and research purposes. Although there is a growing awareness and willingness to implement a nationwide EHR to fully leverage EHR potential, several key organizational, technical, and human barriers impede its effective implementation. ConclusionsThis study investigates the status of EHR implementation in Morocco. It presents some barriers to the successful implementation of nationwide EHR. Findings along with the experiences of developing countries that already succeed in nationwide EHR implementation will help support current efforts.

The Development and Validation of Data Elements and Process Steps for an Electronic Health Record for Hand Surgery Outreach Trips

Background The surgical burden in low- and middle-income countries (LMICs) as reported by the number of surgical cases per capita is great. To improve global health and help address this burden, there has been a rise in surgical outreach to LMICs. In high-income countries, an electronic health record (EHR) is used to document and communicate data critical to the quality of care and patient safety. Despite this, there is little guidance or precedence on the data elements or processes for utilizing an EHR on outreach trips. We validated data elements and process steps for utilizing an EHR for hand surgery outreach trips.Methods We conducted a literature review to identify data elements collected during surgical outreach trips. A future-state process map for the collection and documentation of data elements within an EHR was developed through literature review and semistructured interviews with experts in global outreach. An expert consortium completed a modified RAND/University of California at Los Angeles Delphi process to evaluate the importance and feasibility of each data element and process step.Results In total, 65 data elements (e.g., date of birth) and 24 process steps (e.g., surgical site marking) were validated for use in an EHR for hand surgery outreach trips to LMICs.Conclusion This validated portfolio of data elements/process steps can serve as the foundation for pilot testing of an EHR to document and communicate critical patient data on hand surgery outreach trips. Utilization of an EHR during outreach trips to LMICs may serve to improve the safety and quality of care provided. The validated data elements/process steps can serve as a guide for EHR development and implementation of other surgical specialties.

Representative Participation in a Large-Scale Health IT Project

User involvement is widely recognized as best practice in the development of information technology (IT) systems. In large-scale IT projects, the involvement of users and other stakeholder groups is typically in the form of representatives, as opposed to the direct (in-person) participation characteristic for smaller projects. The potential new sharing of power that representative participation entails vis-à-vis direct stakeholder involvement, and the implications of such a shift, are an important discussion in the context of participatory design. This paper extends and adds to previous work on this subject. Drawing on stakeholder interviews conducted as part of a case study of an electronic health record implementation project in Norway, this paper seeks to describe and analyze problems that can arise with representative participation in a large-scale project. Our focus is on an observed decline of interaction between health professionals participating actively in the project and their advisory units consisting of colleagues without a formal project role. The paper describes how the project’s structural arrangements might explain this decline. The paper also describes how the participating health professionals’ involvement of the advisory units at regular intervals early in the project (broad involvement) was replaced by more ad hoc and competence-oriented approaches (narrow involvement). We further use the organizational structure of democracies as the basis for two analogies, (I) participants-as-political-representatives and (II) participants-as-technocrats. The observed decline in interaction between the participating health professionals and their advisory units can be seen as a transition in role from user representative to technocrat. Generalizing from the case, we suggest that (1) a project’s structure strongly affects the possibilities of participating users to consult other users (e.g., non-participating colleagues) about issues concerning the design solution, (2) a project’s structure conditions the role of participating users and who, or what, they represent, and (3) representative participation requires rethinking a project’s structure.

Responding to change: Could co-design overcome the complexities of electronic health record implementation?

Chang argues that CHAT analysis can facilitate understanding of EHR implementation by turning our attention to its complex interplay with the whole process of medical care.

Contextual Barriers to Implementing Open-Source Electronic Health Record Systems for Low- and Lower-Middle-Income Countries: Scoping Review.

Low- and lower-middle-income countries account for a higher percentage of global epidemics and chronic diseases. In most low- and lower-middle-income countries, there is limited access to health care. The implementation of open-source electronic health records (EHRs) can be understood as a powerful enabler for low- and lower-middle-income countries because it can transform the way health care technology is delivered. Open-source EHRs can enhance health care delivery in low- and lower-middle-income countries by improving the collection, management, and analysis of health data needed to inform health care delivery, policy, and planning. While open-source EHR systems are cost-effective and adaptable, they have not proliferated rapidly in low- and lower-middle-income countries. Implementation barriers slow adoption, with existing research focusing predominantly on technical issues preventing successful implementation. This interdisciplinary scoping review aims to provide an overview of contextual barriers affecting the adaptation and implementation of open-source EHR systems in low- and lower-middle-income countries and to identify areas for future research. We conducted a scoping literature review following a systematic methodological framework. A total of 7 databases were selected from 3 disciplines: medicine and health sciences, computing, and social sciences. The findings were reported in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. The Mixed Methods Appraisal Tool and the Critical Appraisal Skills Programme checklists were used to assess the quality of relevant studies. Data were collated and summarized, and results were reported qualitatively, adopting a narrative synthesis approach. This review included 13 studies that examined open-source EHRs' adaptation and implementation in low- and lower-middle-income countries from 3 interrelated perspectives: socioenvironmental, technological, and organizational barriers. The studies identified key issues such as limited funding, sustainability, organizational and management challenges, infrastructure, data privacy and protection, and ownership. Data protection, confidentiality, ownership, and ethics emerged as important issues, often overshadowed by technical processes. While open-source EHRs have the potential to enhance health care delivery in low- and lower-middle-income-country settings, implementation is fraught with difficulty. This scoping review shows that depending on the adopted perspective to implementation, different implementation barriers come into view. A dominant focus on technology distracts from socioenvironmental and organizational barriers impacting the proliferation of open-source EHRs. The role of local implementing organizations in addressing implementation barriers in low- and lower-middle-income countries remains unclear. A holistic understanding of implementers' experiences of implementation processes is needed. This could help characterize and solve implementation problems, including those related to ethics and the management of data protection. Nevertheless, this scoping review provides a meaningful contribution to the global health informatics discipline.

Measurement and automation of workflows for improved clinician interaction: upgrading EHRs for 21st century healthcare value.

In this editorial, we highlight 5 manuscripts that address aspects of clinician interaction with the electronic health record (EHR). A Perspective describes the efforts of the Office of the National Coordinator for Health Information Technology (ONC) in establishing priorities for workflow automation in healthcare settings.1 A second Perspective summarizes a panel sponsored by the American College of Medical Informatics (ACMI) at the 2021 AMIA Symposium that examined a provocative question: Are EHRs dumbing down clinicians?2 Three manuscripts focus on what can be learned from EHR audit log data.3–5 First, Zayas-Cabán et al1 describe how the ONC led a multidisciplinary effort of stakeholders from industrial engineering, computer science, and finance to investigate automation in health care. They define automation as “the creation and application of technology to monitor and control the delivery of products and services.”6 The process of key informant interviews, focus groups, and a review of pertinent literature identified 6 priorities and their related strategies for advancing workflow automation. These priorities focused on leveraging high quality, interoperable data, and engaging clinicians in the EHR design, implementation, and evaluation processes. Then, relevant, and effective workflows could be identified that add value, not a burden, in clinician processes. The supporting strategies revolved around education, convening multiple interested parties, prioritizing appropriate workflows, and using policies and the market to incentivize automated solutions' development, testing, and evaluation. Examples of priority workflows for automation include reimbursement and prior authorizations, medication reconciliation, care management for newly diagnosed patients, and public health and adverse event reporting. The goal is to upgrade EHR technology to increase efficiency, improve health outcomes, and deliver more value for patients, caregivers, clinicians, and staff involved in healthcare. These priorities and strategies provide some solutions to the inadequacies of EHRs as outlined by Melton et al.2

Codeine prescribing practices before and after the 2017 FDA warning at an academic health system

BackgroundIn April of 2017, the U.S. Food and Drug Administration (FDA) issued a boxed warning contraindicating codeine use in all patients younger than 12 years of age. ObjectivesThe purpose of this study was to describe changes in codeine prescribing practices across a broad range of professions and specialties before and after the boxed warning and identify opportunities for optimization of a health system-wide response to changes in evidence-based practice recommendations. MethodsPatients younger than 12 years of age with codeine-containing products prescribed between February 2017 and April 2018 at a single health system were included. Patient demographics, provider specialty, and prescription indication were collected by retrospective chart review. For categorical variables, frequency and percentage were calculated; for continuous variables, means with standard deviations or medians with interquartile ranges were calculated. ResultsCodeine prescriptions for patients younger than 12 years of age declined after the boxed warning issued by the FDA. Some provider specialties reacted promptly whereas others took longer to change their practice. Temporally, the largest decreases in prescribing centered around the month after the FDA communication release in April 2017 and the later implementation of electronic health record (EHR) alerts in June 2017. ConclusionGiven the persistence of codeine prescribing even after EHR soft-stop alerts were implemented, future pharmacy informatic responses to changes in evidence-based practice recommendations could be optimized using hard-stop alerts for high-impact recommendations. Studies comparing combination codeine products and other opioid medications for chronic pain in pediatric patients would be helpful to characterize the true level of risk in this population.

Clinical Pharmacy Services Enhanced by Electronic Health Record (EHR) Access: An Innovation Narrative.

Patient care in the community pharmacy setting is often hindered due to limited access to adequate patient health information (PHI). Various studies suggest that lack of access to PHI is a main reason for delay in pharmaceutical care, medication dispensing errors, and lacking interprofessional relationships between prescribers and pharmacists. Literature has shown that interprofessional collaboration and improved access to PHI can improve transitions of care and communication for pharmacists, but literature is sparse on implementation of electronic health record (HER) access within independent community pharmacies. This observational study follows implementation of HER access into a rural community pharmacy to enhance common clinical services carried out by pharmacy staff. Metrics include number of enhanced consultations by pharmacy staff, type of consultations provided, potential reimbursement, decreased need to follow up with other providers, potential for decreased time to treatment or refills, and aspects of EHR most utilized during search. Two-hundred sixty three patients' profiles were assessed, with 164 (62.4%) deemed appropriate for EHR access and searching. Most interventions made were related to cardiovascular, endocrinologic, neuropsychiatric, and COVID-19 therapy medications. EHR access in community pharmacy has the potential to improve both the quality and availability of clinical patient interventions through enhanced knowledge of PHI.

Improving Patient Access to the My HealtheVet Electronic Patient Portal for Veterans.

The US Department of Veterans Affairs My HealtheVet (MHV) patient portal is a secure online tool that provides patients access to personal health information. Although facilitators exist to encourage veteran registration, barriers to both adoption and use among veterans persist. This quality improvement project sought to improve veteran access to MHV. Using Plan-Do-Study-Act (PDSA) methodology, we identified barriers to registration, evaluated processes for enrollment, and integrated a process improvement champion into a rural primary care clinic workflow. After 3 PDSA cycles, the integration of new processes resulted in increased enrollment and engagement with MHV. Fourteen veterans registered for MHV at the point-of-care in a 3-month time frame. Use of a connected electronic health record platform and implementation of an MHV champion in the outpatient primary care setting improved rural veteran access to personal health information. Audit and feedback on processes that provide access to health information is an important strategy to narrow the gap between veterans who access patient portals and those who do not.

Role of Electronic Healthcare Record Adoption in Enhancing the Relationship between Quality Measures and Hospital Financial Performance

Electronic Health Records (EHRs) are designed as a real-time digital record to streamline distinctive and valuable patient information across multiple stakeholders in the healthcare delivery channel. The stakeholders include hospitals, healthcare providers and patients, as well as a myriad of third-party providers (i.e., insurance companies, Medicare). Academicians, practitioners and public policy makers are grappling with uneven experiences and empirical findings regarding the relationship between technology-enabled information sharing and the ensuing quality of healthcare outcomes. The most significant government-mandated technology is the implementation and adoption of EHR. The present research examines EHR through the lens of Resource Advantage Theory –– to empirically assess how partial and comprehensive implementation levels of EHR adoption influence quality management and financial performance of hospitals. Based on archival data attained from 210 hospitals in the state of Texas, the results indicate positive relationships between EHR and the quality of care. While it is generally recognized that EHR and quality management affect a hospital’s performance, this research investigates the moderating effect that EHR has on quality management and a hospital’s performance. These findings provide hospital administrators, practitioners, and third-party payers with an integrative and parsimonious model to understand the impact of partial and comprehensive levels of EHR implementation on the relationship of healthcare quality and hospital performance.

Improving Hepatitis C Screening in Inpatient Psychiatry.

Improving Hepatitis C Screening in Inpatient Psychiatry.

Training physicians and residents for the use of Electronic Health Records-A comparative case study between two hospitals.

Despite widespread use of Electronic Health Records (EHR), the promise of benefits has not been clearly realised due, in part, to inadequate physician training. Training for EHR use is a highly complex intervention that occurs in a dynamic socio-technical health system. The purpose of this study was to describe and critically assess the interplay between educational activities and organisational factors that influenced EHR training and implementation across two different hospitals. Based in a socio-technical framework, a comparative qualitative case study was undertaken as well suited to real-world processes. Semi-structured interviews were completed (n = 43), representing administrative leaders, staff physicians, residents and EHR trainers from two Canadian academic hospitals. Thematic analysis was employed for analysis. Similar findings were noted at both hospitals despite different implementation strategies. Despite mandatory training, physicians described limited transferability of training to the workplace. Factors contributing to this included standardised vendor modules (lacking specificity for their clinical context); variable EHR trainer expertise; limited post-launch training; and insufficient preparation for changes to workflow. They described learning while caring for patients and using workarounds. Strong emotional responses were described, including anger, frustration, anxiety and fear of harming patients. Training physicians for effective EHR utilisation requires organisational culture transformation as EHRs impacts all aspects of clinical workflows. Analytic thinking to consider workflows, ongoing post-launch training and the recognition of the interdependency of multiple factors are critical to preparing physicians to provide effective clinical care, and potentially reducing burnout. A list of key considerations is provided for educational leaders.

Implementation of Electronic Health Record System in Ghana: A Review

There are several pieces of evidence to prove that electronic health records (EHRs) can improve the quality of service, efficiency, safety, and positive patient outcomes. Past decades have seen rapid growth in EHR system implementation in healthcare institutions in developing countries. Effective implementation of EHR system provides a unique opportunity to collect a wide range of patient data to support health tracking over a time period. This study seeks to make a case as to why despite some EHR system implementations in Ghana, there has not been any significant improvement in patient outcomes. This research is not a systematic review but assesses the implementation challenges of EHRs in Ghana. Several papers were identified by searching through some databases, including Google Scholar, PubMed, and Medline, using the following topics: EHR implementation, EHR implementation challenges, and EHR system implementation and EHR challenges in Ghana. The approach to the implementation of EHR system largely depends on the country dynamics and does not necessarily follow top-down or bottom-up methods. The focus should also be on the institution and whether they have the resources to make the project implementation successful. End-users should be an integral part of the whole implementation process, and their recommendations should be followed and implemented.

Electronic health record closed-loop referral (“eReferral”) to a state tobacco quitline: a retrospective case study of primary care implementation challenges and adaptations

BackgroundHealth system change can increase the reach of evidence-based smoking cessation treatments. Proactive electronic health record (EHR)-enabled, closed-loop referral (“eReferral”) to state tobacco quitlines increases the rates at which patients who smoke accept cessation treatment. Implementing such system change poses many challenges, however, and adaptations to system contexts are often required, but are understudied. This retrospective case study identified adaptations to eReferral EHR tools and implementation strategies in two healthcare systems.MethodsIn a large clustered randomized controlled trial (C-RCT; NCT02735382) conducted in 2016–2017, 11 primary care clinics in two healthcare systems implemented quitline eReferral, starting with 1 pilot clinic per system followed by 2 phases of implementation (an experimental phase in 5–6 test clinics per system and then a system-wide dissemination phase in both systems). Adaptations were informed by stakeholder input from live trainings, follow-up calls and meetings in the first month after eReferral launch, emails, direct observation by researchers, and clinic staff survey responses. Retrospective, descriptive analysis characterized implementation strategy modifications and adaptations using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS). A pre- and post-implementation survey assessed staff ratings of eReferral acceptability and implementation barriers and facilitators.FindingsMajor modifications to closed-loop eReferral implementation strategies included aligning the eReferral initiative with other high-priority health system objectives, modifying eReferral user interfaces and training in their use, modifying eReferral workflows and associated training, and maintaining and enhancing interoperability and clinician feedback functions. The two health systems both used Epic EHRs but used different approaches to interfacing with the quitline vendor and integrating eReferral into clinician workflows. Both health systems engaged in iterative refinement of the EHR alert prompting eReferral, the eReferral order, trainings, and workflows. Staff survey comments suggested moderate acceptability of eReferral processes and identified possible targets for future modifications in eReferral, including reducing clinician burden related to EHR documentation and addressing clinicians’ negative beliefs about patient receptivity to cessation treatment.ConclusionsSystem-wide implementation of tobacco quitline eReferral in primary care outpatient clinics is feasible but requires extensive coordination across stakeholders, tailoring to local health system EHR configurations, and sensitivity to system- and clinic-specific workflows.Trial registrationwww.clinicaltrials.gov, NCT02735382. Registered on 12 August 2016.

Electronic Health Records in Dental Education: A Scoping Review and Quantitative Analysis of Publications

The use of Electronic Health Records (EHRs) by dentists is already a reality in several countries, including Brazil, both in private practices and in higher education institutions, also providing data for oral health surveillance and epidemiology. The purpose of this scoping review was to search the literature for publications on the importance, applicability, efficacy and ease of the use of electronic medical records in dental education. Following the terms of the PRISMA-ScR, this review sought publications on the use of EHRs in dentistry schools. The databases used in the search were Pubmed, BVS, Web of Science, Scopus and ProQuest, without language limitations and publication period, using the terms ‘Dental School’, ‘Dental Education’ and ‘Electronic Health Records’. Initially, the search resulted in 548 articles. After reading the abstract, full text and removing duplicates, 63 were included. Then, it was divided in three groups according to main thematic: EHRs implementation (n = 25); Data obtained from Dental Schools EHRs used for publications (n = 26); EHRs system efficacy and challenges (n = 12). The use of electronic medical records in the teaching of dentistry collaborates positively with the development of students during graduation. We believe that this alternative of searching and collecting information will be increasingly used in epidemiological studies, due to its practicality and objectivity.

Electronic Health Records in Dental Education: A Scoping Review and Quantitative Analysis of Publications

The use of Electronic Health Records (EHRs) by dentists is already a reality in several countries, including Brazil, both in private practices and in higher education institutions, also providing data for oral health surveillance and epidemiology. The purpose of this scoping review was to search the literature for publications on the importance, applicability, efficacy and ease of the use of electronic medical records in dental education. Following the terms of the PRISMA-ScR, this review sought publications on the use of EHRs in dentistry schools. The databases used in the search were Pubmed, BVS, Web of Science, Scopus and ProQuest, without language limitations and publication period, using the terms ‘Dental School’, ‘Dental Education’ and ‘Electronic Health Records’. Initially, the search resulted in 548 articles. After reading the abstract, full text and removing duplicates, 63 were included. Then, it was divided in three groups according to main thematic: EHRs implementation (n = 25); Data obtained from Dental Schools EHRs used for publications (n = 26); EHRs system efficacy and challenges (n = 12). The use of electronic medical records in the teaching of dentistry collaborates positively with the development of students during graduation. We believe that this alternative of searching and collecting information will be increasingly used in epidemiological studies, due to its practicality and objectivity.

Impact of Implementing Electronic Health Records on Medication Safety at an HIMSS Stage 6 Hospital: The Pharmacist's Perspective.

Medication errors can cause severe injuries and may lead to death. Electronic health records (EHRs) that are well designed and implemented could help to reduce medication errors. The medication management process needs close study to understand how medication safety metrics evolve as hospitals mature in terms of their EHR implementation. To examine the effect of adopting EHRs on medication errors at the Royal Commission Hospital in Jubail, Saudi Arabia, a Health Information Management System Society (HIMSS) stage 6 hospital. This study had a quasi-experimental time-series design. Retrospective data were collected for 1.5-year periods before and after implementation of EHRs. The variables analyzed were obtained from various units in the study setting. Data on medication errors were collected from the risk management section of the quality department. The medication management process was studied qualitatively. The quantitative data were analyzed using descriptive and inferential statistics. The median number of medication orders per patient showed a significant decrease, from 22.76 before EHR implementation to 18.76 after implementation (p < 0.001). The median number of incidents per patient showed a significant increase, from 0.029 before to 0.040 after implementation (p = 0.004). The qualitative analysis of processes involved in the medication management process helped to explain these changes. Contrary to expectations, this study showed that an HIMSS stage 6 hospital could experience an increase in medication errors following implementation of EHRs. Qualitative analysis showed that the increase in medication error reporting rate could be attributed to an increase in detection following improvement in the medication management process. This has implications for interpreting quality metrics as hospitals mature in terms of their EHR implementation.

Improving the User Experience with Discount Site-Specific User Testing.

Poor electronic health record (EHR) usability is associated with patient safety concerns, user dissatisfaction, and provider burnout. EHR certification requires vendors to perform user testing. However, there are no such requirements for site-specific implementations. Health care organizations customize EHR implementations, potentially introducing usability problems. Site-specific usability evaluations may help to identify these concerns, and "discount" usability methods afford health systems a means of doing so even without dedicated usability specialists. This report characterizes a site-specific discount user testing program launched at an academic medical center. We describe lessons learned and highlight three of the EHR features in detail to demonstrate the impact of testing on implementation decisions and on users. Thirteen new EHR features which had already undergone heuristic evaluation and iterative design were evaluated over the course of three user test events. Each event included five to six users. Participants used think aloud technique. Measures of user efficiency, effectiveness, and satisfaction were collected. Usability concerns were characterized by the type of usability heuristic violated and by correctability. Usability concerns occurred at a rate of 2.5 per feature tested. Seventy percent of the usability concerns were deemed correctable prior to implementation. The first highlighted feature was moved to production despite low single ease question (SEQ) scores which may have predicted its subsequent withdrawal from production based on post implementation feedback. Another feature was rebuilt based on usability findings, and a new version was retested and moved to production. A third feature highlights an easily correctable usability concern identified in user testing. Quantitative usability metrics generally reinforced qualitative findings. Simplified user testing with a limited number of participants identifies correctable usability concerns, even after heuristic evaluation. Our discount usability approach to site-specific usability has a role in implementations and may improve the usability of the EHR for the end user.