Campaign Seeks Push to Improve Usability of EHRs

Published on: 

A campaign is underway to ask Congress to implement pieces of previous legislation aimed at improving electronic health records (EHRs) in order to reduce physician burnout and improve patient safety.

A campaign is underway to ask Congress to implement pieces of previous legislation aimed at improving electronic health records (EHRs) in order to reduce physician burnout and improve patient safety.

The joint campaign from the American Medical Association and MedStar Healt launches during the 10-year anniversary month of the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act. The campaign website,, displays videos, collected from previous research, that depict common EHR problems: difficult data entry, challenging visual display, and complicated workflows. MedStar built the website based on research they published last year on the usability of Cerner and Epic EHRs, which dominate the market.

In previous interviews with The American Journal of Managed Care®, Raj M. Ratwani, PhD, an EHR safety researcher and director of the MedStar Health National Center for Human Factors in Healthcare, has discussed the issue of poor EHR visability, which may contribute to patient harm. For example, in 1 video on the website, if an EHR order had processed in real life, the patient would have been severely underdosed with norepinephrine.


The problems with EHRs come from multiple factors: the data is not asked for in a way that providers think about their work; computations are not automatic; data entry process can be unforgiving.

Compared with other forms of technology and displays that most people have come to expect by now (eg, search engines that accurately predict what one is searching for or that correct common spelling mistakes) EHR interfaces can seem clunky and outdated, and are not intuitive. In addition, many EHR products become further customized by a specific client, which adds to their layer of complexity or introduce unintended consequences.

In addition to the HITECH Act, the 21st Century Cures Act of 2016 included the creation of an EHR Reporting Program, where the Office of the National Coordinator (ONC) for Health Information Technology (HIT), the HHS office responsible for implementing and advancing the use of health information technology, would collect and disseminate data on core EHR features, including usability.

However, ONC implementation has moved slowly; only last year did it put out a call for public comments about improving the EHR Reporting Program.

The campaign website encourages visitors to send letters to Congressional leaders, asking that Congress work to include “objective measures of safety as part of usability criteria” as well as a way for “clinicians and patients to directly report on EHR usability and safety.”

In an accompanying Viewpoint published this week in JAMA, Ratwani and coauthors wrote that in the 10 years since the 2009 law was passed, “the scope of usability challenges is much larger than anticipated, and useful research findings have not been effectively translated by industry.” They suggest 5 strategies that policy makers, industry leaders, and others should implement:

  • Create a national database of usability and safety issues. This would require vendor concerns about intellectual property to be addressed, but it should not stop the sharing of this information, the authors wrote. They envision something like the FDA’s Manufacturer and User Facility Device Experience database. Within it, clinicians would report and illustrate various types of usability issues, and should allow sharing of safety-related software information, to prevent similar events from happening with other products.
  • Establish basic design standards. The authors noted that other high-risk industries, such as aviation and ground transportation, have design standards that promote usability, such as standards for font color and size. The authors said while ONC has not previously embraced usability standards, “its 2018 draft strategy plan for reducing clinician burden from HIT use discusses standards.”
  • Address unintended harms. To address the multiple factors that can create mistakes that lead to patient harm, “alignment of vendor, health care organization, and clinician accountability, such as shared liability for harms caused by poor usability,” must be addressed, the authors said.
  • Simplify mandated documentation requirements that affect usability. Vendors and ONC need to collaborate so that anything that must be included in a federal reporting requirement is done so in the most streamlined and simple manner.
  • Standardize usability and safety measures. Currently, HIT products cannot be directly compared due to a lack of standard measure of usability. To start, standardized test case scenarios should become part of the ONC’s certification program. Results from scenario testing should drive iterative product improvement and eventually encourage market adoption.


Ratwani RM, Reider J, Singh H. A decade of health information technology usability challenges and the path forward [publihsed online February 4, 2019]. JAMA. doi:10.1001/jama.2019.0161.