The Need to Optimize the Electronic Health Record: Usability Issues
in Legacy Systems Can Compromise Patient Safety
Rebecca A. Meehan
School of Information, Kent State University, 1125 Risman, Kent, OH, U.S.A.
Keywords: EHR, Usability, EHR Optimization.
Abstract: It is imperative that usability issues affecting patient safety continue to be fixed in the electronic health record
(EHR), especially in legacy systems that may not be updated or replaced for years to come. EHR developers
and vendors are partners with hospital systems and clinicians in identifying, prioritizing and fixing problems
in the EHR that may adversely affect patient safety. Many of these issues are identified by clinicians as issues
of poor usability. This presentation discusses current processes for identifying, prioritizing and fixing
usability issues as they arise in the implemented or legacy system by both vendors and hospital groups.
Strategies for how to improve processes moving forward are discussed.
As we strive to improve health care by leveraging
advancements in health information technology, it is
imperative to fix usability issues affecting patient
safety in the electronic health record (EHR) both in
new system implementations and in existing legacy
systems. This addresses the recommendation by the
American Medical Association (AMA, 2014) when it
recommended strategies for improving care by
improving EHR usability. Among eight
recommendations, the AMA report calls for methods
to expedite user input into EHR design and to gather
post-implementation feedback. Usability fixes
recommended by end-users are part of the post-
implementation feedback but may be stymied by an
organizational culture or infrastructure that is not
prepared to offer feedback, or at least timely detailed
feedback. There can be propensity for organizations
to justify enduring with their existing EHR, despite
poor usability because of competing priorities, or
other flawed justifications such as the team can find
workarounds for the issue, or they should just wait
and the issue will be corrected in a new system.
However, the new system might be years away. And,
for usability issues that are impacting patient safety
outcomes, there is no time to wait.
This paper describes the foundational pieces to an
on-going research project examining the current
processes and strategies for improvement for
identifying, prioritizing, and fixing usability issues as
they arise in the implemented or legacy system by two
major stakeholder partners: EHR developers/
vendors and hospital groups. These issues can be
seen as part of EHR optimization, or the timing in the
EHR implementation cycle of making the EHR the
most effective, efficient, and supportive it can be.
(Romero & Staub, 2016). This includes identifying
processes and elements that have poor usability,
resulting in harm or the potential to harm patients.
The steps to examine the practices of how errors and
usability issues related to the EHR are resolved
include the following:
Step 1 How are issues identified: who reports the
issue and to whom (a supervisor, information
technology (IT) representative, EHR vendor
Step 2 How are issues prioritized: what is the process
for collecting the list of issues and assigning them
with high priority or low priority (committees, unit
supervisor, IT department, EHR vendor, CMIO).
Step 3 When these EHR usability problems
compromising patient safety are indeed fixed, how
long does it typically take and what is the process for
getting the fix implemented into the system, and
communicating the fix to stakeholders, especially the
original reporter.
These process components of addressing usability
issues in the built legacy EHR from the perspective of
both the EHR vendors and the hospital/ health
provider stakeholder groups are critical to improving
patient safety.
Meehan, R.
The Need to Optimize the Electronic Health Record: Usability Issues in Legacy Systems Can Compromise Patient Safety.
DOI: 10.5220/0009107106090613
In Proceedings of the 13th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2020), pages 609-613
ISBN: 978-989-758-398-8
2020 by SCITEPRESS Science and Technology Publications, Lda. All rights reserved
2.1 Rapid Adoption of the EHR
In the United States (US), the Health Information
Technology for Economic and Clinical Health
(HITECH) Act, as part of the American Reinvestment
and Recovery Act (2009) provided financial
incentives for eligible providers and hospitals to
adopt EHRs and use them meaningfully. As a result,
there was a rapid increase of EHR adoption from 9%
of all hospitals with a basic EHR in 2008 to over 96%
of all hospitals using a certified EHR in 2017
-Hospital-EHR-Adoption.php). This rapid adoption
and implementation cycle have been criticized
(Schulte & Fry, 2019) for how it likely created risk
for EHRs to be implemented that met requirements,
but also had some usability issues that may result in
unintended consequences compromising patient
2.2 Benefits of the EHR
The EHR is used worldwide to maintain health
records, transforming the way clinicians and patients
interact with health information. The EHR
contributes to improved quality of health care through
improved visibility of data, allowing for a more
complete health record to be stored, accessed and
shared. The EHR has transformed healthcare in that
it enables clinicians to have more information about a
patient’s medical history, diagnosis, allergies,
medications, imaging and lab results, etc. in order to
inform the best care possible. Beyond these
advantages, the EHR also brings challenges and
unintended adverse consequences associated with
poor EHR usability.
2.3 What Is Usability?
Usability is defined as how useful, usable and
satisfying a system is for the intended users to
accomplish goals in their work (Zhang & Walji,
2011). In order for the EHR to have good usability,
the software should be intuitive, and easy to use so
that clinicians and other stakeholders to get their jobs
done, without the stress of not understanding how to
use the system. For clinicians, this means getting the
right information, for the right patient at the right
time, so that information about the patient’s health
history, medications and current status can inform the
best care possible. In today’s digital health
environment, so much more information can be
presented to the clinician in the care process (e.g.
medication information, imaging, social determinants
of health, allergies, prior health status, etc.). The
numerous data sources have the potential to provide a
more comprehensive view of a patient’s health.
However, poor usability can, not only jeopardize this
ability for the clinician, but it also can lead to patient
harm. For example, the clinician may choose to
prescribe a medication. These medications are often
presented in the EHR using a data field or drop-down
selection box. So, in this example, it is critical for the
drop-down box to show the full name and dosage
amount, and not have that view obscured or shortened
so that the wrong medication or dosage is selected
accidentally. Obviously, by selecting the wrong
dosage or medication, the patient could be harmed.
Not only are there compromises to patient safety, but
poor usability affects the clinicians who use them.
The EHR system needs to be easy to use, in order to
minimize the fatigue of end users, and to allay
clinician burnout (Gardner, et al, 2019). Poor
usability in the EHR, being used in the context of a
stressful health care setting has resulted in unintended
consequences compromising patient safety (Howe, et
al, 2018) and new unintended consequences (Sittig, et
al, 2016).
2.4 Unintended Consequences
Campbell and colleagues (2006) describe several
unintended adverse consequences of computerized
provider order entry (CPOE) systems a few of which
include more/new work for clinicians, changed
communication patterns, unfavourable workflow
issues, generation of new kinds of errors, unexpected
changes in power structure, and overdependence on
the technology. These issues continue to shape the
efficiency and effectiveness of the EHR by virtue of
the effect on the end users, both individually and as
part of organizational culture. As a result, work
patterns, expectations and satisfaction levels change.
Despite tremendous progress in EHRs, unintended
adverse consequences of the EHR have evolved over
the years. Sittig and colleagues (2016) described new
unintended adverse consequences of the EHR, some
of which include complete clinical information
unavailable at the point of care, inadvertent
disclosure of large amounts of patient-specific
information; a decline in the development and use of
internally-developed EHRs, and lack of innovations
to improve system usability leading to frustrating user
experiences. This evolution of unintended adverse
consequences is indicative of the exponential growth
HEALTHINF 2020 - 13th International Conference on Health Informatics
in the use of EHRs, as well as the tremendous
capability of the systems.
Substantial increases in the amount of time
required to interact with the EHR by clinicians and
other hospital staff is changing clinical care patterns
and interactions with patients. Clinicians are
reporting lower levels of job satisfaction and early
burnout (Gardner, et al, 2019). This experience can be
made worse by poor EHR usability, disrupting
workflow and creating workarounds. Staff burnout
continues to be an issue, and strategies to ameliorate
this call for technology solutions to be improved by
clinician-vendor collaboration in design and
deployment (The Lancet, editorial, 2019).
2.5 Legacy System
A legacy EHR system is one that has been
implemented and used by a hospital system or
provider office for over three years. A legacy system
is not brand new, but it is one that the organization is
living with or has lived with for quite a while. As
technology evolves, EHRs are delivered and
maintained on different technological platforms, each
with different ways in which they can offer updates
to health care provider and hospital clients. These
platforms include local on- site servers, software as a
service, and cloud-based systems. Regardless of
platform, fixes to the software can be delivered in a
few different ways. 1) Software fixes delivered as
“patches” are made available with the most frequency
and can offer a temporary fix to an error, until the
code is incorporated into the new upgrade base code.
2) Fixes to high priority issues to live systems that
need immediate attention can be delivered as
“hotfixes.” 3) A “system update” to the software
occurs with some regularity but can be less frequent
and tend to include several fixes or enhancements to
a system. The time it takes for a usability issue with
the EHR to be identified, prioritized and fixed will
vary widely. Because of this, communication back to
the original person reporting the usability issue can be
inefficient and ineffective.
2.6 Communication
Communicating the details of these fixes is important
so that the clinicians who originally called for the fix
can see that the change has been made. If there is too
much time that elapses between the original request
and the fix, the danger is that inefficient workarounds
will continue to be used. Moreover, it slows down
progress and improvements. Any type of fix to the
EHR software is typically communicated with some
form of release notes, so that when the client applies
the fixes, other stakeholders can read what changes
are being addressed in the fix. Mis-communication
issues can arise when the release notes are not readily
available, or if clinicians on site at the hospital or
health provider do not read the notes, and hence may
not be informed until they use the system and see that
it is running differently. This communication is
important so that clinicians can stop using
workarounds and start using the EHR as intended.
2.7 EHR Optimization in Legacy
EHR implementation has been the focus of efforts by
vendors, hospitals, consulting groups, and both
government-based and independent organizations for
health care quality over the past several years. Now
that, as of 2017, 96% of hospitals in the US have
implemented certified EHRs
-Hospital-EHR-Adoption.php, accessed 11-9-19),
stakeholders have an opportunity to make these
systems more effective and efficient as part of an
EHR optimization phase (see Figure 1).
Figure 1: Cycle of EHR Implementation and Optimization.
EHR optimization is the process that takes place
after implementation to maximize the benefits and
utility of the system (Moon, et al, 2018). Others have
described EHR optimization as ongoing, and
necessary to be incorporated into each organization’s
structure and culture (Blavin, et al, 2013). In a like
manner, system maintenance is continuing, and can
facilitate optimization. Overall, it is in the phase of
EHR optimization that usability issues compromising
patient safety can be identified, prioritized and fixed.
This ongoing vigilance about how the system should
be working is critical. To that end, it is important to
identify best practices to support optimization and to
make improvements in care and patient safety
EHR System
The Need to Optimize the Electronic Health Record: Usability Issues in Legacy Systems Can Compromise Patient Safety
When hospital end users encounter a problem with
the usability of the EHR, leading to potential for
patient safety concerns, they need to have an
organized way of getting it fixed. Part of this can be
addressed by voluntarily completing a patient safety
report on site in the hospital to give others visibility
to the issue. Another part of the process involves
taking necessary steps to bring the issue to the
attention of the EHR developer/ vendor. This process
not only requires an efficient and effective process on
the health care provider/ hospital side, but also with
their EHR vendor/ developers. A partnership
between the hospital and the vendor is a necessity in
order to facilitate post-implementation feedback and
to optimize the EHR by fixing the system to avoid
errors that may compromise patient safety.
3.1 EHR Developers/ Vendors
There is little to no literature on the best practices of
EHR optimization from the EHR developer/ vendor
stakeholder group. Still, developers and vendors have
processes in place for continuous improvement
including the timely fixes made as the EHR product
is supported and given new modifications under
standard maintenance. Fixes to the system or
improvements to the system are typically driven by
product enhancements or additional functionality that
did not make it into the first release of the product,
but, instead were planned as part of future releases, in
which clients would be able to take an upgrade to their
system for these new pieces of functionality.
Changes by the developer/ vendor to the EHR are also
driven by enhancement requests and fixes/ tickets
requested by the hospital / health provider client.
These requests need to be prioritized and decisions
need to be made on if and when they will be fixed for
the client’s EHR system. Moreover, decisions are
made on how the clients will be able to take and apply
these fixes to their system: will it be a patch made
available immediately for one client or more clients,
part of a routine update to the software, made
available at the next release, or will these changes be
incorporated into a new product release altogether,
and available for an additional cost to existing
clients? These decisions about priorities are typically
made by the product team and may not be uniformly
applied. Many usability related requests often make
it onto the product backlog, waiting for a time to be
incorporated into the system. And many of these
backlog issues have a hard time seeing the light of
day. Many EHR vendors/ developers have talked
about struggles with moving items from the backlog
and into the current sprint (for an agile development
process) and into the product.
Inevitably, product teams and usability experts
need to advocate for these usability changes to be
made to the existing system. This can be difficult to
prioritize these fixes over delivering new
functionality or working around ever changing
regulatory requirements for the EHR. This is a
continuing cycle, and one that needs attention in order
to understand best practices. In a like manner,
hospitals/ providers need to have an efficient and
effective way of fixing usability problems in legacy
EHR systems.
3.2 Hospitals/ Clinical Provider
Hospital systems need to find efficient processes to
identify these usability issues that need to be fixed
within the EHR, because organizations typically “live
with” these systems between 7-10 years before new
and updated systems are implemented. There are
occasional updates to the EHR, but those are typically
made on individual components and are not
comprehensive. These processes are part of EHR
optimization, the continuous process of assessing the
system for ways to improve efficiency (Romero &
Staub, 2016).
There is a limited literature on work done in this
area, however, Moon and colleagues (2018) used a
qualitative approach to conduct interviews and focus
groups with high performing health care
organizations in the US. Results from their study
describe relevant issues that arise during the
optimization process, including the exponential
uptick in software enhancement or change requests
after the product go-live. There was no associated
process of efficiently addressing these concerns.
Recommendations from the study include that
hospitals/ health providers should dedicate resources
to addressing optimization issues going forward.
4.1 Partnership between Vendors and
Clinical Providers
Moving forward, the way to optimize the EHR to
protect patient safety outcomes stemming from
usability fixes may be to rely on a partnership
between EHR vendors / developers and clinical or
HEALTHINF 2020 - 13th International Conference on Health Informatics
hospital providers. Both stakeholder groups play a
role in the organization of a strategy and commitment
to the continuing process of identifying, prioritizing,
fixing and communicating fixes on the EHR back to
all stakeholders.
4.2 Future Research
In order to evaluate the current status and practices
for identifying, prioritizing and fixing patient safety
issues related to poor usability in legacy EHR
systems, Kent State University (USA), led by the
author, is conducting survey research among both
EHR vendors and hospital systems in the United
States. Key metrics include:
descriptors of the size and type of hospital or EHR
number of patient safety related fixes to the EHR
reported vs. number of fixes made;
descriptors of platform types of EHR products
used or made (e.g. cloud based, local install);
identification of where fixes are made (on-site at
the hospital IT department or at the EHR vendor
description of current process to identify,
prioritize and fix patient safety issues related to
description of what in the current process is
working well and what needs to be improved.
This study will be divided into two phases, one for
each stakeholder group: 1) EHR developers and
vendors, and 2) hospitals/ clinical providers. Data
collection is ongoing. Implications for patient safety
outcomes related to EHR optimization processes will
be discussed.
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The Need to Optimize the Electronic Health Record: Usability Issues in Legacy Systems Can Compromise Patient Safety