- The arrival of the electronic health record (EHR) in healthcare has brought just as many challenges as it has benefits, with patient advocates often citing poor EHR usability as the root cause of adverse patient safety events.
To enhance EHR usability, and to reduce patient harm, the Pew Charitable Trusts, in collaboration with the American Medical Association (AMA) and Medstar Health, convened a panel of providers, EHR vendors, and health IT experts to develop recommendations and criteria that will ensure optimal performance throughout the EHR lifecycle.
“Current certification tests are focused on evaluating the usability of key system requirements,” the organizations wrote.
“Several additional best practices, criteria, and factors emerged from the expert panel discussions that could help EHR developers and health care facilities improve product usability and safety. These criteria could provide the foundation for a voluntary certification program.”
Mindfully designing and optimizing EHRs
When designing EHR systems, vendors should prioritize the needs of providers, the experts said.
“Developers should follow principles of user-centered design, such as by obtaining frequent user feedback at multiple points in development and establishing user ‘personas’ that reflect the typical needs of different types of clinicians,” the team wrote.
Vendors can also observe clinical workflows and request provider contributions to shaping the product’s usability.
In addition to being mindful of EHR design, developers and providers should consider the possible issues that come with EHR optimization and customization.
“As customization in each facility is unique based on its workflows, configuration can help optimize the safe use of the system. However, customization can also introduce risk,” advised the panel.
The experts suggested that vendors provide evidence-based feedback from previous implementations and customizations before making changes to existing workflows.
Providers looking to optimize their health IT systems should communicate their reasons for these proposed changes to vendors and assess their organizations’ capacity to customize EHRs.
If vendors do make customizations to the EHR, clinicians should document the changes and develop risk mitigation plans for each modification.
Testing EHRs to enhance health IT performance
Prior to implementing an EHR, it is critical that providers and vendors vigorously test the new system.
The panel recommended that test cases feature different types of providers, each with various levels of clinical and technological expertise, to ensure the system works for every end-user and workflow within the organization.
Vendors and providers should also conduct test cases with specific, clinically-oriented goals in mind. Each goal should be paired with clear measures of success and failure.
“The lack of such goals and measures for each test case could complicate the ability to assess the use of EHRs in concrete ways, although goals and measures may vary from implementation to implementation,” the experts said.
The team stressed that test cases must also include known risk areas that rarely occur but can contribute to serious patient harm.
These areas may include routine events with a non-routine action, such as delivering triplets instead of a single patient birth, or complex activities that require difficult cognitive processes, such as integrating clinical information from multiple sources.
“Testing known areas of risk will help to identify these challenges and prevent them from persisting in the product,” the panel wrote.
“Focusing on areas that could produce inefficiencies or challenging tasks can help to implement corrections that can address clinician concerns.”
Ensuring optimal implementation and EHR upgrades
Before implementing an EHR system, vendors and providers should have a comprehensive plan in place to correct any issues that may occur.
“Vendors should develop an implementation plan, based on experience, and share it with the healthcare provider’s implementation teams,” the experts said.
“Providers should also have a clear governance structure in place to support implementation processes and address safety challenges that arise.”
The panel also advised that developers identify any communication gaps that may hinder the implementation process, and utilize any available resources from clinicians that can enhance EHR implementation.
On the provider side, organizations can create multidisciplinary teams to facilitate implementation and develop consensus on functionality and workflows.
When an upgrade is necessary, developers should communicate clearly with customers to prevent misunderstandings about operational changes or system performance.
“Developers should commit to providing safety-based software upgrades and general system maintenance at a reasonable cost and in a feasible manner,” the team said.
“Providers should install appropriate software upgrades, particularly when recognized safety enhancements are included, and implement system upgrades in a timely manner upon release.”
When developing system upgrades, the panel also emphasized that vendors should ensure the new software can integrate seamlessly with older versions, and providers should evaluate the risks that can come with each upgrade.
Creating and promoting a culture of health IT safety
To ensure health IT systems don’t contribute to patient harm after implementation, vendors and providers should establish a culture of safety around EHR use and training.
The experts recommended that both vendors and providers create a risk-free environment where personnel can report potential safety hazards. Organizations should also have established methods in place for clinicians to report potential safety risks.
EHR developers should examine the causes of potential risks and do their best to fix them, the panel said.
“When hazards are identified, developers should perform root-cause analysis, collect corrective actions, and make sure they are implemented,” the report stated.
The experts also suggested that developers and clinicians participate in health IT safety organizations and patient safety collaboratives to share information and opportunities for improvement.
Additionally, when training providers on new EHR technology, leaders should consider users’ specific needs and abilities and continuously offer health IT training to providers.
“Training should be tailored to the needs of the trainees and be readily accessible,” the experts wrote.
“This type of training can occur through the use of simulations around workflows, refresher training at various intervals, continuous access to training materials, and an opportunity for enhanced training to those in need.”
EHR developers should also actively involve end-users in training exercises, as well as disclose training recommendations to clinicians and IT staff early in the purchasing process.
With these recommendations, Pew, AMA, and MedStar expect that both providers and vendors will be able to improve EHR usability and support patient safety.
“The adoption of best practices—including the tenets of the safety-focused certification criteria and more robust testing scenarios—can help give EHR developers and healthcare facilities better information to detect challenges and reduce the potential of avoidable patient harm,” the panel concluded.