WASHINGTON, D.C. —Improving electronic health record (EHR) systems, to eliminate challenges that can lead to patient harm and make EHRs more efficient and less time-consuming for clinicians, can be achieved with certain policy changes that allow for sharing of information among end users, researchers and developers, according to an opinion piece published today in the Journal of the American Medical Association. The article was written by Raj Ratwani, PhD, a leading EHR usability expert with MedStar’s National Center for Human Factors in Healthcare, and two collaborators, Michael Hodgkins, MD, of the American Medical Association, Chicago, and David W. Bates, MD, of Brigham and Women’s Hospital, Boston.
Currently, a barrier to improving EHR usability and safety is that the contracts between EHR vendors and healthcare systems contain “gag clauses” that prevent providers from freely and openly discussing challenges and sharing solutions. For example, providers cannot share screenshots or videos of the usability or safety issues they encounter, without permission from the EHR vendor, a process that can be lengthy and cumbersome. Vendors cite protection of intellectual property for such contract provisions, but end users and safety experts argue that patient safety and clinician needs should take precedence. In comparison, medical device companies are required to share usability and safety issues. While EHRs represent a major technology advancement in health care, they have introduced new challenges and some specific types of safety issues, which Dr. Ratwani and others have documented, written about frequently, and given as testimony to federal policymakers and congressional committees.
“One of the biggest challenges has been that many clinicians report that EHRs are difficult to use, require too much time to perform certain tasks, and create frustration in performing other tasks, especially those performed infrequently. EHR usability, which is the extent to which this technology can be used efficiently, effectively, and safely by clinicians to deliver care, has emerged as one of the most pressing issues in health care,” they write in the current article. They further contend that the lack of transparency about EHR usability issues “represents a market failure.”
Congress has sought to address this issue with specific language in the 21st Century Cures Act of 2016 that prevents vendors from prohibiting or restricting the communication of EHR usability information. Now, it is up to the Office of the National Coordinator of Health Information Technology to define the provisions and what constitutes blocking.
Dr. Ratwani and his co-authors recommend three criteria to create transparency that would promote more usable and safer EHR technology:
- Policies to ensure vendors support usability testing by enabling use of test environments and rigorous test cases
- Policies to prohibit vendors from blocking their healthcare organization clients from participating in usability and safety studies
- Policies to require vendors to permit the timely dissemination of information relating to usability and safety issues to enable a comparison of specific challenges across products
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About the MedStar Health National Center for Human Factors in Healthcare
The MedStar Health National Center for Human Factors in Healthcare occupies a unique position in the United States as the largest human factors program embedded within a healthcare system. It brings together human factors scientists, systems safety engineers, health services researchers, clinicians, and other experts to create a safer and more efficient healthcare environment through four core services in research, usability, safety advisement, and education. The center is part of the MedStar Institute for Innovation and is also affiliated with the MedStar Health Research Institute and MedStar Institute for Quality and Safety. MedStar Health, the parent organization, is the largest not-for-profit healthcare provider in the Maryland and Washington, D.C., region, with 10 hospitals and an extensive ambulatory services network, and is the medical education and clinical partner of Georgetown University.
About Raj Ratwani, PhD
Dr. Ratwani is the Director of MedStar Health’s National Center for Human Factors in Healthcare and is an Assistant Professor of Emergency Medicine at Georgetown University’s School of Medicine. His research is focused on improving the usability and safety of health information technology.
In addition to his research efforts, he works to inform health policy. He has testified in front of, and advised, the U.S. Senate Health, Education, Labor and Pensions (HELP) committee and several other federal advisory committees focused on improving health information technology safety and accessibility for patients. He has been selected to serve on the 21st Century Cures Act Health Information Technology Advisory Committee to advise the Department of Health and Human Services.
He holds a PhD in Human Factors and Applied Cognition and B.S. in Cognitive Science. He was a National Research Council postdoctoral fellow at the U.S. Naval Research Laboratory.
Previous Research on EHR Usability and Safety: Dr. Ratwani has published extensively on EHR usability and safety. Major articles include the following, and additional publications are listed here:
- Examining EHR usability and patient safety.
Ratwani, R.M., Savage, E., Will, A., Fong, A., Karavite, D., Muthu, N., Rivera, A.J., Gibson, C., Asmonga, D., Moscovitch, B. and Grundmeier, R., 2018. Identifying Electronic Health Record Usability And Safety Challenges In Pediatric Settings. Health Affairs, 37(11), pp.1752-1759.
Howe, J. L., Adams, K. T., Hettinger, A. Z., & Ratwani, R. M. (2018). Electronic Health Record Usability Issues and Potential Contribution to Patient Harm. Journal of the American Medical Association (JAMA), 319(12): 1276-1278.
Ratwani, R.M., Savage, E., Will, A., Arnold, R., Khairat, S., Miller, K., Fairbanks, R.J., Hodgkins, M. & Hettinger, A.Z. (2018). A Usability and Safety Analysis of Electronic Health Records: a Multi-Center Study. Journal of the American Medical Informatics Association.
- Examining EHR vendor usability processes.
Ratwani, R.M., Fairbanks, R.J., Hettinger, A.Z. & Benda, N. (2015). Electronic Health Record Usability: Analysis of the User Centered Design Processes of Eleven Electronic Health Record Vendors. Journal of the American Medical Informatics Association.
- Examining EHR vendor adherence to usability and safety policies.
Ratwani, R.M., Benda, N., Hettinger, A.Z., & Fairbanks, R.J. (2015) Electronic Health Record Vendor Adherence to Usability Certification Requirements and Testing Standards. Journal of the American Medical Association (JAMA) 314(10):1070-1071.
- Comparing policies on EHR usability and safety to other industries.
Savage, E., Fairbanks, R.J., & Ratwani, R.M. (2017). Are informed policies in place to promote safe and usable EHRs? A cross industry comparison. Journal of the American Medical Informatics Association.
- Demonstrating the impact of EHRs on clinician performance.
Benda, N., Meadors, M., Hettinger, A.Z & Ratwani, R.M. (2015). Emergency Physician Task Switching Increases with the Introduction of a Commercial Electronic Health Record. Annals of Emergency Medicine.
- A framework for comparing the usability of EHRs and challenges with comparing usability.
Ratwani, R.M., Hettinger, A.Z., Kosydar, A., Fairbanks, R.J. & Hodgkins, M. (2016). A Framework for Evaluating Electronic Health Record Vendor User Centered Design and Usability Testing Processes. Journal of the American Medical Informatics Association. Ocw 092.
Ratwani, R.M., Hettinger, A.Z., Fairbanks, R.J. (2016). Barriers to Comparing the Usability of Electronic Health Records. Journal of the American Medical Informatics Association.
- Implications of EHR downtime on patient safety.
Larsen, E., Fong, A., Wernz, C., & Ratwani, R. M. (2018). Implications of electronic health record downtime: an analysis of patient safety event reports. Journal of the American Medical Informatics Association. 25 (2), 187-191.